Molecular Diagnosis & Therapy

, Volume 10, Issue 2, pp 77–91 | Cite as

New Strategies for Blood Donor Screening for Hepatitis B Virus

Nucleic Acid Testing versus Immunoassay Methods
Infectious Diseases


Serologic testing for hepatitis B virus (HBV) surface antigen (HBsAg) and antibody to HBV core antigen (anti-HBc) has historically been the foundation of blood screening, while HBV nucleic acid testing (NAT) was recently developed to detect HBsAg-negative, anti-HBc-negative blood units donated during early acute infection. Comparison data on seroconversion panels using HBsAg assays of varying sensitivities and pooled- or single-sample NAT, along with viral load estimates corresponding to HBsAg assay detection limits, have provided information on the theoretical benefits of NAT relative to HBsAg. Model-derived estimates have generally been predictive of the yields of DNA-positive, HBsAg-negative window period blood units detected in a number of studies from Europe, Japan, and the US. Studies indicate that the added benefit of pooled-sample NAT is relatively small in areas of low endemicity, with greater yields in areas highly endemic for HBV. Single-sample NAT would offer more significant early window period closure and could prevent a moderate number of residual HBV transmissions not detected by HBsAg assays; however, no fully automated single-sample HBV NAT systems are currently available.

Even single-sample HBV NAT may not substitute for anti-HBc screening, as indicated by studies of donors with isolated anti-HBc who have extremely low DNA levels undetectable by standard single-sample NAT and who have been associated with transfusion-transmitted HBV. Moreover, HBsAg testing may still be needed even in the setting of combined anti-HBc and NAT screening. HBsAg-positive units from donors in the chronic stage of infection may contain very low or intermittently detectable DNA levels that single-sample NAT would miss. Although such donors are usually anti-HBc reactive and would be interdicted by anti-HBc screening, some lack anti-HBc. Extensive parallel testing will be needed to determine whether single-sample NAT in combination with anti-HBc might be sufficient to detect all the infectious donors currently interdicted by HBsAg testing. In countries that do not screen for anti-HBc, HBsAg testing would be the only means of detecting donations from chronically infected individuals with low/intermittently detectable DNA, since even single-donor NAT would not identify these potentially infectious blood units.

In the future, the current fully automated HBsAg assays may incorporate significant sensitivity improvements, and automated single-sample HBV NAT may become a reality. Each country will need to develop its blood screening strategy based on HBV endemicity, yields of infectious units detected by different serologic/NAT screening methods, and cost effectiveness of test methods in ensuring blood safety.


  1. 1.
    World Health Organization. Hepatitis B [online]. Available from URL: [Accessed 2005 Sep 13]
  2. 2.
    Kuhns MC. Viral Hepatitis part I: the discovery, diagnostic tests, and new viruses. Lab Med 1995; 26(10): 650–9Google Scholar
  3. 3.
    Allain J-P. Occult hepatitis B infection: implications in transfusion. Vox Sang 2004; 86: 83–91PubMedCrossRefGoogle Scholar
  4. 4.
    Stramer SL, Glynn SA, Kleinman SH, et al. Detection of HIV-1 and HCV infections among antibody-negative blood donors by nucleic acid-amplification testing. N Engl J Med 2004; 351(8): 760–8PubMedCrossRefGoogle Scholar
  5. 5.
    Coste J, Reesink HW, Engelfriet CP, et al. Implementation of donor screening for infectious agents transmitted by blood by nucleic acid technology: update to 2003. Vox Sang 2005; 88: 289–303PubMedCrossRefGoogle Scholar
  6. 6.
    Kleinman SH, Busch MP. HBV: amplified and back in the blood safety spotlight. Transfusion 2001; 41: 1–5CrossRefGoogle Scholar
  7. 7.
    Tabor E, Epstein JS. NAT screening of blood and plasma donations: evolution of technology and regulatory policy. Transfusion 2002; 42: 1230–7PubMedCrossRefGoogle Scholar
  8. 8.
    Busch MP. Should HBV DNA NAT replace HBsAg and/or anti-HBc screening of blood donors? Transfus Clin Biol 2004; 11: 26–32PubMedCrossRefGoogle Scholar
  9. 9.
    Stramer SL. Pooled hepatitis B virus DNA testing by nucleic acid amplification: implementation or not. Transfusion 2005; 45: 1242–6PubMedCrossRefGoogle Scholar
  10. 10.
    Schreiber GB, Busch MP, Kleinman SH, et al. The risk of transfusion transmitted viral infections. N Engl J Med 1996; 334: 1685–90PubMedCrossRefGoogle Scholar
  11. 11.
    Korelitz JJ, Busch MP, Kleinman SH, et al. A method for estimating hepatitis B virus incidence rates in volunteer blood donors. Transfusion 1997; 37: 634–40PubMedCrossRefGoogle Scholar
  12. 12.
    Glynn SA, Kleinman SH, Schreiber GB, et al. Trends in incidence and prevalence of major transfusion-transmissible viral infections in US blood donors, 1991-1996. JAMA 2000; 284(2): 229–35PubMedCrossRefGoogle Scholar
  13. 13.
    Dodd RY, Notari EP, Stramer SL. Current prevalence and incidence of infectious disease markers and estimated window-period risk in the American Red Cross blood donor population. Transfusion 2002; 42: 975–9PubMedCrossRefGoogle Scholar
  14. 14.
    Seed CR, Cheng A, Ismay SL, et al. Assessing the accuracy of three viral risk models in predicting the outcome of implementing HIV and HCV NAT donor screening in Australia and the implications for future HBV NAT. Transfusion 2002; 42: 1365–72PubMedCrossRefGoogle Scholar
  15. 15.
    Pillonel J, Laperche S. Trends in risk of transfusion-transmitted viral infections (HIV, HCV, HBV) in France between 1992 and 2003 and impact of nucleic acid testing (NAT). Eurosurveillance 2005; 10(2): 5–6PubMedGoogle Scholar
  16. 16.
    Offergeld R, Faensen D, Ritter S, et al. Human immunodeficiency virus, hepatitis C and hepatitis B infections among blood donors in Germany 2000–2002: risk of virus transmission and the impact of nucleic acid amplification testing. Eurosurveillance 2005; 10(2): 13–4Google Scholar
  17. 17.
    Alvarez do Barrio M, Diez RG, Sanchez JMH, et al. Residual risk of transfusion-transmitted viral infections in Spain, 1997–2002, and impact of nucleic acid testing. Eurosurveillance 2005; 10(2): 11–2Google Scholar
  18. 18.
    Soldan K, Davison K, Dow B. Estimates of the frequency of HBV, HCV, and HIV infectious donations entering the blood supply in the United Kingdom, 1996-2003. Eurosurveillance 2005; 10(2): 9–10Google Scholar
  19. 19.
    Mimms LT, Mosley JW, Hollinger FB, et al. Effect of concurrent acute infection with hepatitis C virus on acute hepatitis B virus infection. BMJ 1993; 307: 1095–7PubMedCrossRefGoogle Scholar
  20. 20.
    Biswas R, Tabor E, Hsia CC, et al. Comparative sensitivity of HBV NATs and HBsAg assays for detection of acute HBV infection. Transfusion 2003; 43: 788–98PubMedCrossRefGoogle Scholar
  21. 21.
    Busch MP, Glynn SA, Stramer SL, et al. A new strategy for estimating risks of transfusion-transmitted viral infections based on rates of detection of recently infected donors. Transfusion 2005; 45: 254–64PubMedCrossRefGoogle Scholar
  22. 22.
    Dodd RY. Current safety of the blood supply in the United States. Int J Hematol 2004; 80: 301–5PubMedCrossRefGoogle Scholar
  23. 23.
    Busch MP, Watanabe KK, Smith JW, et al. False-negative testing errors in routine viral marker screening of blood donors. Transfusion 2000; 40: 585–9PubMedCrossRefGoogle Scholar
  24. 24.
    Sato S, Kato T, Ikeda H, et al. Estimated risk of transfusion-transmitted infection. In: Symposium on limit of prevention of transfusion-related adverse reactions. Proceedings of the 7th Japanese Red Cross Blood Symposium; Tokyo, Japan; 1999 Feb 27. Tokyo: Japanese Red Cross Central Blood Center, 1999: 3-12Google Scholar
  25. 25.
    World Health Organization. Report of WHO Working Group on international reference preparations for testing diagnostic kits used in the detection of HBsAg and anti-HCV antibodies. November 2003 [online]. Available from URL: [Accessed 2005 Sep 14]
  26. 26.
    Mizuochi T. Re-evaluation of HBsAg detection kits approved for marketing in Japan. Jpn J Infect Dis 2001; 54: 201–7Google Scholar
  27. 27.
    Sato S, Ohhashi W, Ihara H, et al. Comparison of the sensitivity of NAT using pooled donor samples for HBV and that of a serologic HBsAg assay. Transfusion 2001; 41: 1107–13PubMedCrossRefGoogle Scholar
  28. 28.
    Grant PR, Busch MP. Nucleic acid amplification technology methods used in blood donor screening. Transfus Med 2002; 12: 229–42PubMedCrossRefGoogle Scholar
  29. 29.
    Saldanha J, Gerlich W, Lelie N, et al. An international collaborative study to establish a World Health Organization international standard for hepatitis B virus DNA nucleic acid amplification techniques. Vox Sang 2001; 80: 63–71PubMedCrossRefGoogle Scholar
  30. 30.
    Koppelman M, Assal A, Chudy M, et al. Multicenter performance evaluation of a transcription-mediated amplification assay for screening of human immunodeficiency virus-1 RNA, hepatitis C virus RNA, and hepatitis B virus DNA in blood donations. Transfusion 2005; 45: 1258–66PubMedCrossRefGoogle Scholar
  31. 31.
    Drosten C, Weber M, seifried E, et al. Evaluation of a new PCR assay with competitive internal control sequence for blood donor screening. Transfusion 2000; 40: 718–24PubMedCrossRefGoogle Scholar
  32. 32.
    Roth WK, Weber M, Petersen D, et al. NAT for HBV and anti-HBc testing increase blood safety. Transfusion 2002; 42: 869–75PubMedCrossRefGoogle Scholar
  33. 33.
    Minegishi K, Yoshikawa A, Kishimoto S, et al. Superiority of minipool nucleic acid amplification technology for hepatitis B virus over chemiluminescence immunoassay for hepatitis B surface antigen screening. Vox Sang 2003; 84: 287–91PubMedCrossRefGoogle Scholar
  34. 34.
    Kleinman SH, Strong DM, Tegtmeier GG, et al. Hepatitis B virus (HBV) DNA screening of blood donations in minipools with the COBAS AmpliScreen HBV test. Transfusion 2005; 45: 1247–57PubMedCrossRefGoogle Scholar
  35. 35.
    Kuhns MC, McNamara AL, Peterson B, et al. Detection of hepatitis B seroconversion by highly sensitive assays for surface antigen and HBV DNA [abstract S342]. Transfusion 1998; 38 Suppl. 10: 91SGoogle Scholar
  36. 36.
    Stramer SL, Brodsky JP, Preston SB, et al. Comparative sensitivity of HBsAg and HBV NAT [abstract S23-0300]. Transfusion 2001; 41 Suppl. 9S: 8SGoogle Scholar
  37. 37.
    Yoshikawa A, Gotanda Y, Itabashi M, et al. Hepatitis B NAT virus-positive blood donors in the early and late stages of HBV infection: analyses of the window period and kinetics of HBV DNA. Vox Sang 2005; 88: 77–86PubMedCrossRefGoogle Scholar
  38. 38.
    Kuhns MC, Kleinman SH, McNamara AL, et al. Lack of correlation between HBsAg and HBV DNA levels in blood donors who test positive for HBsAg and anti-HBc: implications for future HBV screening policy. Transfusion 2004; 44: 1332–9PubMedCrossRefGoogle Scholar
  39. 39.
    Kleinman SH, Kuhns MC, Todd DS, et al. Frequency of HBV DNA detection in US blood donors testing positive for the presence of anti-HBc: implications for transfusion transmission and donor screening. Transfusion 2003; 43: 696–704PubMedCrossRefGoogle Scholar
  40. 40.
    Dreier J, Kroger M, Diekmann J, et al. Low-level viraemia of hepatitis B virus in an anti-HBc- and anti-HBs-positive blood donor. Transfus Med 2004; 14: 97–103PubMedCrossRefGoogle Scholar
  41. 41.
    Kuhns M, McNamara A, Mason A, et al. Serum and liver hepatitis B virus DNA in chronic hepatitis B after sustained loss of surface antigen. Gastroenterology 1992; 103: 1649–56PubMedGoogle Scholar
  42. 42.
    Kuhns MC, McNamara AL, Perrillo R. Intermittent PCR positivity for hepatitis B viral DNA in surface antigen negative anti-core positive individuals [abstract S432-0300]. Transfusion 1999; 39 Suppl. 10S: 95SGoogle Scholar
  43. 43.
    Mason AL, Xu L, Guo L, et al. Molecular basis for persistent hepatitis B virus infection in the liver after clearance of serum hepatitis B surface antigen. Hepatology 1998; 27(6): 1736–42PubMedCrossRefGoogle Scholar
  44. 44.
    Rehermann B, Ferrari C, Pasquinelli C, et al. The hepatitis B virus persists for decades after patients’ recovery from acute viral hepatitis despite active maintenance of a cytotoxic T-lymphocyte response. Nat Med 1996; 2(10): 1104–8PubMedCrossRefGoogle Scholar
  45. 45.
    Prince AM, Lee D-H, Brotman B. Infectivity of blood from PCR-positive, HBsAg-negative, anti-HBs positive cases of resolved hepatitis B infection. Transfusion 2001; 41: 329–32PubMedCrossRefGoogle Scholar
  46. 46.
    Matsumoto C, Tadokoro K, Fujimura K, et al. Analysis of HBV infection after blood transfusion in Japan through investigation of a comprehensive donor specimen repository. Transfusion 2001; 41: 878–84PubMedCrossRefGoogle Scholar
  47. 47.
    Allain J-P, Hewitt PE, Tedder RS, et al. Evidence that anti-HBc but not HBV DNA testing may prevent some HBV transmission by transfusion. Br J Haematol 1999; 107:186–95PubMedCrossRefGoogle Scholar
  48. 48.
    US Food and Drug Administration. Product approval information — licensing action: frequently asked questions regarding implementation of the Roche Molecular Systems COBAS Ampliscreen HBV test. 21 Apr 2005 [online]. Available from URL: [Accessed 2005 Apr 29]
  49. 49.
    Allain J-P, Sarkodie F, Candotti D, et al. Lack of correlation between hepatitis B surface antigen and hepatitis B virus DNA levels in blood donors. Transfusion 2005; 45: 1039–40PubMedCrossRefGoogle Scholar
  50. 50.
    Loeb KR, Jerome KR, Goddard J, et al. High-throughput quantitative analysis of hepatitis B virus DNA in serum using the TaqMan fluorogenic detection system. Hepatology 2000; 32: 626–9PubMedCrossRefGoogle Scholar
  51. 51.
    Allain J-P, Candotti D, Soldan K, et al. The risk of hepatitis B virus infection by transfusion in Kumasi, Ghana. Blood 2003; 101: 2419–25PubMedCrossRefGoogle Scholar
  52. 52.
    Gotoh K, Mima S, Uchida T, et al. Nucleotide sequence of hepatitis B virus isolated from subjects without serum anti-hepatitis B core antibody. J Med Virol 1995; 46(3): 201–6PubMedCrossRefGoogle Scholar
  53. 53.
    Lee JH, Paglieroni TG, Holland PV, et al. Chronic hepatitis B virus infection in an anti-HBc-nonreactive blood donor: variant virus or defective immune response? Hepatology 1992; 16: 24–30PubMedCrossRefGoogle Scholar
  54. 54.
    Laperche S, Guitton C, Smilovici W, et al. Blood donors infected with the hepatitis B virus but persistently lacking antibodies to the hepatitis B core antigen. Vox Sang 2001; 80(2): 90–4PubMedCrossRefGoogle Scholar
  55. 55.
    Matsuura K, Tobe K, Iwasaki Y, et al. Clinical significance of low or negative titer of antibody to hepatitis B core antigen during the course of chronic hepatitis B virus infection in adolescents. Gastroenterol Jpn 1993; 28(1): 25–33PubMedGoogle Scholar
  56. 56.
    Lee SD, Lo KJ, Tsai YT, et al. HBsAg carrier infants with serum anti-HBc negativity. Hepatology 1989; 9(1): 102–4PubMedCrossRefGoogle Scholar
  57. 57.
    Ni YH, Hsu HY, Chang MH, et al. Absence or delayed appearance of hepatitis B core antibody in chronic hepatitis B surface antigen carrier children. J Hepatol 1993; 17(2): 150–4PubMedCrossRefGoogle Scholar
  58. 58.
    Chan CY, Lee SD, Yu MI, et al. Long-term follow-up of hepatitis B virus carrier infants. J Med Virol 1994; 44(4): 336–9PubMedCrossRefGoogle Scholar
  59. 59.
    Terada T, Moriyama M, Uchida T, et al. Nucleotide sequence of the precore/core gene and X gene of hepatitis B virus DNA in asymptomatic hepatitis B virus carriers who are negative for serum hepatitis B core antibody. Intervirology 2001; 44(4): 243–9PubMedCrossRefGoogle Scholar
  60. 60.
    Motoyoshi F, Kondo N, Terasawa K, et al. Impaired response to HBcAg in a hepatitis B virus carrier. J Invest Allergol Clin Immunol 1995; 5(6): 350–3Google Scholar
  61. 61.
    Zoulim F, Zhang X, Pichoud C, et al. Heterogeneity of hepatitis B virus (HBV) core gene in a patient with HBV-associated cirrhosis and serum negativity for anti-HBc. J Hepatol 1996; 24(2): 155–60PubMedCrossRefGoogle Scholar
  62. 62.
    Fiordalisi G, Primi D, Tanzi E, et al. Hepatitis B virus C gene heterogeneity in a familial cluster of anti-HBc negative chronic carriers. J Med Virol 1994; 42(2): 109–14PubMedCrossRefGoogle Scholar
  63. 63.
    Lazizi Y, Dubreuil P, Pillot J. Excess HBcAg in HBc antibody-negative chronic hepatitis B virus carriers. Hepatology 1993; 17(6): 966–70PubMedGoogle Scholar
  64. 64.
    Echevarria JM, Leon P, Pozo F. Hepatitis B virus surface antigen reactivity in the absence of antibodies to core antigen: an atypical serological pattern having diverse significance. Enferm Infecc Microbiol Clin 2004; 22(1): 6–12PubMedCrossRefGoogle Scholar
  65. 65.
    Laperche S. Blood safety and nucleic acid testing in Europe. Eurosurveillance 2005; 10(2): 1–2Google Scholar
  66. 66.
    Pereira A. Health and economic impact of posttransfusion hepatitis B and cost-effectiveness analysis of expanded HBV testing protocols of blood donors: a study focused on the European Union. Transfusion 2003; 43: 192–201PubMedCrossRefGoogle Scholar
  67. 67.
    Jackson BR, Busch MP, Stramer SL, et al. The cost-effectiveness of NAT for HIV, HCV, and HBV in whole-blood donations. Transfusion 2003; 43: 721–9PubMedCrossRefGoogle Scholar
  68. 68.
    Marshall DA, Kleinman SH, Wong JB, et al. Cost-effectiveness of nucleic acid test screening of volunteer blood donations for hepatitis B, hepatitis C and human immunodeficiency virus in the United States. Vox Sang 2004; 86: 28–40PubMedCrossRefGoogle Scholar
  69. 69.
    Valanne A, Huopalahti S, Vainionpaa R, et al. Rapid and sensitive HBsAg immunoassay based on fluorescent nonparticle labels and time-resolved detection. J Virol Methods 2005; 129: 83–90PubMedCrossRefGoogle Scholar
  70. 70.
    Ackermann H, Hesse P, Liese R, et al. Testing of infectious disease parameters using LOCI technology on the Dimension Vista system [abstract D-62]. Clin Chem 2005; 51 Suppl. 6: A175Google Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  1. 1.Abbott DiagnosticsAbbott ParkUSA
  2. 2.Blood Systems Research InstituteSan FranciscoUSA
  3. 3.University of CaliforniaSan FranciscoUSA

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