Hepatitis B virus blood screening: unfinished agendas

The risk of transfusion-transmitted hepatitis B virus (TTHBV) has been steadily reduced through the use of volunteer donors, enhanced donor questioning, and increasingly sensitive hepatitis B surface antigen (HBsAg) tests. In a few countries, screening by antibody to hepatitis B core antigen (anti-HBc) and/or hepatitis B virus (HBV) nucleic acid amplification tests (NAT) has also been introduced. Nevertheless, the risk of TTHBV in most countries is higher than the risk of either human immunodeficiency virus-1 (HIV-1) or hepatitis C virus (HCV). HBV screening practices vary both in terms of the markers screened and the tests employed, and are often dependent on a country's healthcare resources. Anti-HBc screening could be employed as an additional safety feature in HBV low-prevalence countries, but would lead to the rejection of a high percentage of otherwise acceptable donations in HBV moderate- and high-prevalence countries. It has been argued that only individual-donor HBV NAT testing would substantially reduce the risk of TTHBV beyond that achieved by the most sensitive HBsAg tests. However, studies from countries with low, moderate and high HBV prevalence have demonstrated NAT yield from window period- and late stage HBV-infected donors, even using minipool testing following the most sensitive HBsAg tests.