Hep B Blog

You’ve Lost the Hepatitis B Surface Antigen, Go Celebrate, But Keep Monitoring

By Christine Kukka

Image courtesy of stockimages at FreeDigitalPhotos.net
Image courtesy of stockimages at FreeDigitalPhotos.net

After years of living with “inactive’ chronic hepatitis B—with low viral load and no signs of liver damage–some patients may finally lose the hepatitis B surface antigen (HBsAg) and even develop surface antibodies.

This event merits a celebration and a huge sigh of relief, but if you think you will never have to get another blood draw or worry about your liver, think again. We hate to be the bearer of bad news, but hepatitis B really never goes away.

Image courtesy of stockimages at FreeDigitalPhotos.net
Image courtesy of stockimages at FreeDigitalPhotos.net

Think herpes, mono, or chicken pox and shingles. Children infected with chickenpox get rid of the infection and the ugly blisters, but very small amounts of the chickenpox (varicella) virus remains in the spinal nerves. As we grow older and our immune systems weaken with age,  our bodies aren’t able to suppress the varicella virus any more and it reactivates, causing painful shingles.

The hepatitis B virus (HBV) behaves in the same way. When we lose HBsAg and even develop surface antibodies (anti-HBs), there are still HBV lurking in our livers. When we’re healthy, our immune systems suppress the virus and prevent any reactivation, but old age or another disease or medical condition can weaken our bodies and allow the viral infection to reactivate.

So, even after we clear HBsAg, we need to stay vigilant and continue to get our liver health monitored regularly. Here is what you need to know:

First, what are my chances of ever getting rid of HBsAg and developing the surface antibody? It can happen, especially in older adults after a long period of “inactive” hepatitis B infection.

About 1 to 3 percent of people with chronic hepatitis B lose HBsAg each year, and about half of all people with chronic infections who live up to age 75 will lose HBsAg, depending on the amount of HBV DNA in their blood.

Your chances of losing HBsAg and developing the surface antibody increase if you have a healthy lifestyle and avoid alcohol, cigarettes and obesity (fatty liver). Another report found that people with the hepatitis B strain or genotype C have higher rates of clearing HBsAg over time than those with genotype B.

Image courtesy of taoty at FreeDigitalPhotos.net
Image courtesy of taoty at FreeDigitalPhotos.net

Once you clear HBsAg, the chance of developing surface antibodies over the next two, five and 10 years are 24 percent, 58 percent and 78 percent respectively, according to a recent report in the September 2016 journal of Epidemiology and Infection.

After I clear HBsAg, how often do I need to get my liver health monitored? According to Dr. Robert Gish, medical director of the Hepatitis B Foundation and professor consultant of gastroenterology and hepatology at Stanford University, once you have cleared HBsAg, 12 months later you need to:

  • Check all of your liver enzymes and liver function
  • Get your platelet count and hepatitis B blood tests done, and
  • Have an ultrasound of your liver and spleen.

These tests become your new “baseline” that your doctor can refer too in the years ahead while monitoring your liver health.

Your baseline ultrasound should examine your liver and measure its portal vein (it should be under 12 mm) and spleen (it should be under 12 cm) to make sure it’s normal with no signs of cirrhosis or portal hypertension.

If you had cirrhosis before you cleared HBsAg: You need to be surveyed for liver cancer (with an ultrasound, alpha fetoprotein (AFP) blood test and a Des-gamma-carboxy prothrombin (DCP) test) every six months for at least five years, because cirrhosis puts you at high risk of liver cancer. Once an ultrasound finds no evidence of cirrhosis and all other tests are normal, including the cancer tests, then the testing can become less frequent and your doctor can prescribe a new monitoring schedule.

If you’ve had elevated liver enzymes (called ALT or SGPT) in the past, (higher than 19 in women and 30 in men), you need to continue to get tested every six months until you’ve had two consecutive healthy ALT readings. If your ALT remains elevated, make sure you are not drinking alcohol and do not have fatty liver disease. Talk to your doctor about a new monitoring schedule.

Tell all of your current and future doctors you’ve had hepatitis B, and beware of immune-suppressing drugs used to treat various cancers and rheumatoid arthritis. Our immune systems, which are working to keep the residual HBV in our bodies in check, can also take a hit from medications that deliberately suppress our immune systems in order to fight cancer, psoriasis or rheumatoid arthritis.

According to medical guidelines, all oncologists and other specialists who use these powerful drugs are supposed to test all  their patients for hepatitis B and carefully monitor anyone who had hepatitis B in the past, which is indicated by a positive test for the hepatitis B core antibody (anti-HBc).

Even if you’ve cleared HBsAg, doctors may pre-emptively treat you with antivirals during and after your treatment for cancer, immune disorders such as arthritis or psoriasis, and hepatitis C and monitor your HBsAg and viral load regularly to make sure your hepatitis B does not reactivate.

These screening guidelines exist, but no one is perfect and your oncologist may not know you’ve been infected, may forget to screen you for hepatitis B, or may not understand the testing. So, tell everyone if you have an active or resolved hepatitis B infection. The last thing you want is to be battling both cancer and a reactivated hepatitis B infection simultaneously.

While hepatitis B never really goes away, once you clear HBsAg your risk of liver damage and liver cancer diminish tremendously. It’s worth a celebration, but you need to continue to be monitored as you age.

Comments on this blog are closed. If you have questions about hepatitis B or this blog post, please email info@hepb.org or call 215-489-4900.

17 thoughts on “You’ve Lost the Hepatitis B Surface Antigen, Go Celebrate, But Keep Monitoring”

  1. Hi hepb, I have hepatitis b with in active carries , with normal alt of 30 and DNA of 7000 Ui/ml . Doctors suggested no treatment
    I am going to marry next month . But I can’t tell her about my hep b condition before Mrriage . Is there any way to vaccinate her after few days of my marriage . I heard pregnant women will take antiviral drugs to avoid transferring to child . Similarly is there any way for me to not to transfer to my wife till I vaccinate her

    1. Hello: To have an honest relationship, and to protect your future wife, you should tell her now about your hepatitis B and make sure she is tested for hepatitis B and vaccinated as soon as possible.
      Until she has had all three vaccine doses over the six-month period, you must practice safe sex (use a condom). If you do not, you may infect her and endanger her. Having her vaccinated after the wedding is too late!
      If you have her best interests at heart, you do not want her infected and you don’t want to worry about your future children.
      Once she is vaccinated and has enough hepatitis B antibodies to protect her against infection, you do not have to worry about infecting her or your future children. Good luck.

  2. Hi
    I was diagnosed of hepatitis b but spontaneously resolved and got vaccinated as antibodies had developed.
    Can hepatitis b virus reactivated again?
    Since it is said that hepatitis b virus never goes away from body once infected with hepatitis b?

    1. Hello: If you had acute hepatitis B and resolved it, (and developed hepatitis B surface antibodies), your immune system fought off the infection and generated antibodies that will forever protect you against infection. Getting the vaccine did not play a role in developing immunity, it was your own body. Once you have these antibodies, you cannot be infected again. Good luck.

      1. Immune responses of isolated anti-HBc subjects are not well characterized in populations in China. This study aimed to evaluate immune responses to hepatitis B vaccination in isolated anti-HBc positive subjects. A cohort of 608 subjects were selected and separated into isolated anti-HBc (negative for HBsAg and anti-HBs, positive for anti-HBc) and control (negative for HBsAg, anti-HBs, and anti-HBc) groups, who were matched by age and sex. All subjects received 3 doses of hepatitis B vaccine (20μg) at months 0, 1, and 3, followed by testing for serological responses 1 month after the third vaccination. The positive seroprotection rate and geometric mean titer (GMT) for hepatitis B surface antibody (anti-HBs) of isolated anti-HBc subjects were significantly lower than those in the control group(86.2% vs.92.1%, P = 0.02; 47.26 vs.97.81 mIU/mL, P < 0.001). When stratified by age, positive seroprotection rate in the isolated anti-HBc group were 92%, 88.5% and 79.4% in the 20–34, 35–49, and 50–60 y old subgroups, respectively (χ2 = 5.919, P = 0.04). Additionally, the GMT level for anti-HBs in the isolated anti-HBc group for different age subgroups were 104.43, 47.87 and 31.79 mIU/mL respectively (χ2 = 19.44, P < 0.001). The GMT level for anti-HBc before vaccination were negatively correlated with GMT for anti-HBs after 3 doses of hepatitis B vaccine (r = −0.165, P < 0.001). In conclusion, isolated anti-HBc positive subjects can achieve good immune responses after hepatitis B vaccination, and the positive seroprotection rate and GMT level for anti-HBs were lower than the control group. Better responses could be observed in young adults, and significant negative correlations were found between GMT of anti-HBc before vaccination and GMT of anti-HBs after vaccination. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964834/

  3. Hi I was exposed to hep b wen I was 41 years old but my body has antibodies to fight it off. Now I’m 47 years old and I got a blood test in October everything in my blood work came out inactive but Varian load said high. What does that mean? Am I ok I still worried. Plz explain

    1. Hello: By inactive, do you mean the tests (either ALT or SGPT) showed no signs of liver damage? And, is it your viral load (HBV DNA) that was high? Please send us as much detail as possible so we can help you effectively. Good luck.

  4. Here in my country getting a correct lab result is very difficult. I have been diagnosed with HBsAg in 2016 through my doctor and this site I am able to up keep my health, most test result in my country are done through strip how would someone understand that he has getting rid of HBsAg and after getting rid of HBsAg thus it mean the person is no more infectious, if yes why? if no why ?

    1. Hello: If you no longer test positive for the hepatitis B surface antigen (HBsAg) through a rapid test strip test (if I understand your question correctly), it is good news. Is it possible for you to get tested for the hepatitis B surface antibody (anti-HBs)?
      When people clear an acute hepatitis B infection, it is common to develop surface antibodies, however sometimes after a chronic infection, people simply lose HBsAg and don’t develop surface antibodies. As the blog post suggests, researchers are still working out why this happens.
      I hope I’ve answered your question, please feel free to pose the question again. Good luck.

  5. I was tested positive to hbsag in January this year. My lft was normal in February. Each day after waking, the first memory is my hbv positive statue. The thinking will destroy my whole day. My fear is that this infection is gradually damaging my liver. My question now is when my left is normal does it mean no damage has been caused?.
    Secondly when do we expect those drugs that have the final cure. Thanks

    1. Hello: Please be assured that the majority of people with hepatitis B live long and healthy lives. Please don’t let your hepatitis B define you or your quality of life, you are more than your diagnosis.
      Continue to eat healthy foods and lead a healthy lifestyle, avoid alcohol and cigarettes, practice safe sex, and get monitored every 12 to six months, whatever your doctor recommends.
      Experts predict a cure will be developed in the next few years. Please do not lose hope. Good luck.

  6. Hi..
    I have negative HBV-PCR and positive HBS-Ag … ALT is normal
    This situation about the positive HBS-Ag is destroying my chance to marry or have children…people think that surly i will infect my husband and my children
    Here in arab countries there is no clear idea about my condition …
    By the way im a doctor
    Please …is there any way to get rid of HBS-ag??

    1. Hello: I am sorry you face such discrimination because of your hepatitis B status. Of course you can marry and have children. Your husband simply needs to be vaccinated against hepatitis B, and if/when you have children, as long as they are vaccinated with the first hepatitis B vaccine dose within 12 hours of birth, and give a dose of HBIG (hepatitis B antibodies) they will be free from infection.
      Unfortunately, there is no drug developed yet that clears HBsAg. Doctors and researchers are working hard to find a way to eliminate HBsAg, which would cure both hepatitis B and hepatitis D. Good luck.

  7. Greetings
    This is my second post,I was diagnose with hep b for the first time around 29/03/2017.I started having symptoms of fatigue and poor appepite and yellow urine
    First result
    Hbeag +
    Hbeab +
    Alt 38
    Second result
    Hbeag –
    Hbeab +
    Alt 19
    I am worried I that I can’t clear the virus or I might be among the 5% unlucky
    The issue of poor appepite and fatigue is fading out now but my urine is still yellow

    1. Hello: If you were recently infected and are experiencing an “acute” hepatitis B infection, it can take about six months for your immune system to get rid of the infection.
      The good news is you have lost the hepatitis B “e” antigen (HBeAg) and developed the “e” antibody (antibodies are good!) and with your ALT level of 19, you have no signs of liver damage, which is very good.
      Hopefully your symptoms of fatigue will continue to decrease.
      Considering you were first diagnosed in March, you will have to wait until September for the six-month test to determine if you have cleared the infection.
      In the meantime, eat healthy foods, exercise, and of course avoid alcohol and cigarettes.
      Good luck.

    1. Hello: Good question. Experts predict a cure will be developed in the next several years, it will probably take longer than two years. We remain hopeful and optimistic. Good luck.

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