Hepatitis B and C — Reporting and Clinical Guidelines

Acute Hepatitis B

Acute cases of hepatitis B can be diagnosed based on clinical presentation and/or laboratory criteria. Providers must report patients who:

• Test positive for hepatitis B surface antigen (HBsAg) and present with a discrete onset of any signs or symptoms consistent with acute viral hepatitis:
  • Fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and abdominal pain, and one of the following:
    • Jaundice (including dark urine or pale stool), or
    • Elevated serum alanine aminotransferase (ALT) levels >200 IU/L, or
    • Total bilirubin ≥ 3.0 mg/dL
• Test positive for HBsAg and positive for hepatitis B core immunoglobulin M (IgM) antibody (HBcAb IgM)
• Test positive for hepatitis B envelope antigen (HBeAg) and positive HBcAb IgM
• Test positive for hepatitis B virus DNA (HBV DNA) and positive HBcAb IgM
• Tested negative for HBsAg in the past 12 months and now test positive for hepatitis B (either HBsAg, HBeAg, or HBV DNA). Patients with positive conversion in the past 12 months are considered acute cases and do not require concomitant acute clinical presentation for diagnosis.

Perinatal, Pregnant, and Postpartum Hepatitis B

Providers must report:

• People who are pregnant or postpartum and test positive for HBsAg or HBV DNA
• Infants aged 6 months or older who test positive for HBsAg when tested at least four weeks after completion of hepatitis B vaccine series
• Infants who test positive for HBeAg
• Infants with detectable levels of HBV DNA

Providers should offer hepatitis B vaccination to individuals in the groups below.

Infants and children:

• All infants are recommended to receive the first dose within 24 hours of birth.
• Children younger than 19 years of age are recommended to complete the vaccine series.

Hepatitis B vaccination is required for child care and school attendance in New York State.

Adults:

• All adults aged 19-59 years
• Adults aged 60 years and older with identified risk factors or without identified risk factors but seeking protection.

Providers who do not offer vaccination can search the NYC Health Map for locations offering hepatitis B vaccination or can refer their patients to the Health Department’s Immunization Clinic.

For more guidance, see NYC Dear Colleague letter on updated hepatitis B vaccine recommendations (PDF, 2022).

Providers should offer hepatitis B testing to all adults aged 18 years and older at least once in their lifetime, especially people who were born or whose parents were born in an area where hepatitis B is common.

Infants born to people with hepatitis B and all pregnant people during each pregnancy should be tested for hepatitis B.

Providers should screen and offer periodic hepatitis B testing to people who have an identified risk factor, regardless of age:

• People incarcerated or formerly incarcerated in a jail, prison, or other detention setting
• People with a history of sexually transmitted infections or multiple sex partners
• Men who have sex with men, and transgender people who have sex with men
• People with a sexual partner with hepatitis B
• People who currently or previously lived with someone with hepatitis B
• People who use or inject drugs or shared any drug use equipment, even once
• People with HIV
• People with hepatitis C or history of hepatitis C
• People receiving home or in-center maintenance dialysis, including hemodialysis and peritoneal dialysis
• People who work in health care or public safety and are exposed to blood or body fluids

Additional situations where hepatitis B testing is indicated:

• When initiating HIV PEP or PrEP, or during a monitoring visit if not screened at the start of treatment

• In the setting of immunosuppressive therapies including chemotherapy, organ transplantation, and therapies for autoimmune, rheumatologic, gastrointestinal or dermatological disorders.

Providers should order a screening panel, or triple panel, that includes hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb) and hepatitis B core antibody total (total HBcAb).

For more guidance, see CDC's Clinical Testing and Diagnosis for Hepatitis B.

Providers should offer hepatitis B emergency post-exposure prophylaxis (PEP) or hepatitis B immunoglobulin (HBIG) within seven days of exposure.

If the patient has hepatitis B or tests positive for both HBsAg and HBcAb, providers should:

• Complete a full medical evaluation, including all of the following:
  • Hepatitis B DNA
  • Liver function testing and fibrosis or cirrhosis status
  • Risk factors related to alcohol, metabolic and comorbidities
  • Liver cancer screening
  • Assessing appropriateness for antiviral treatment initiation
• Provide education on the frequency of medical visits, transmission prevention, and how to maintain liver health.
• Encourage screening and vaccination for household, family and sexual contacts.
• Connect patients for support: Hepatitis B Foundation has two storytelling projects, #justB and B the Voice, which showcase the stories in short videos of people with hepatitis B.

If the testing provider cannot provide an assessment and treatment to a patient with hepatitis B, they should refer them to a provider who manages hepatitis B.

If the patient has hepatitis B and C co-infection, see Special Considerations for Key Populations.

Providers are required to test all pregnant people for hepatitis B each pregnancy, preferably during an early prenatal visit (e.g., first trimester), even if they have been vaccinated or tested previously.

Providers should order a prenatal panel that includes the test for HBsAg, even if the patient is known to be chronically infected. Screen with a hepatitis B triple panel if no record of previous complete screening.

If the pregnant person tests positive for HBsAg, or is known to be chronically infected, providers should:

• Test for hepatitis B DNA (quantitative) to determine the need for maternal antiviral therapy during pregnancy to help prevent perinatal hepatitis B transmission.
  • For guidance on maternal antiviral therapy, see the American Association for the Study of Liver Diseases’ (AASLD) Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B.
• Refer pregnant people with hepatitis B to a provider experienced in the management of hepatitis B in pregnancy.
• Include a copy of the original HBsAg laboratory report with medical records sent to the expected delivery facility and advise the patient on the importance of informing the delivery team.
• Plan to administer one dose of the hepatitis B vaccine to the infant (the birth dose) and one dose of the hepatitis B immunoglobulin (HBIG) immediately after birth, no later than 12 hours after delivery. This will help prevent vertical transmission of hepatitis B from birthing person to infant.

If the pregnant person tests negative for HBsAg, providers should:

• Offer hepatitis B vaccination, if not previously vaccinated.
• Retest for HBsAg upon admission to delivery facility if at risk for hepatitis B during pregnancy.

For more guidance, see CDC’s Obstetrical Tip Sheet for Hepatitis B Screening, Testing, and Management of Pregnant Persons (PDF).

After infant delivery, providers should provide vaccination and testing for infants born to hepatitis B positive parents. See CDC’s pediatric provider tip sheet (PDF).

Acute cases of hepatitis C can be diagnosed based on clinical presentation and laboratory criteria. There is no FDA approved laboratory test that distinguishes acute from chronic hepatitis C. The NYC Health Department relies on providers to report new cases of suspected acute hepatitis C.

Providers must report patients who:

• Test positive for hepatitis C virus ribonucleic acid (HCV RNA) via Nucleic Acid Amplification Technique (NAT or PCR) including qualitative, quantitative, or genotype testing and present with a discrete onset of signs or symptoms consistent with acute viral hepatitis:
  • Fever, headache, malaise, anorexia, nausea, vomiting, diarrhea and abdominal pain, and either:
    • Jaundice (including dark urine or pale stool), or
    • Elevated serum alanine aminotransferase (ALT) levels >200 IU/L, or
    • Total bilirubin ≥ 3.0 mg/dL
• Tested negative for hepatitis C antibody (Hep C Ab) or HCV RNA in the past 12 months and now test positive.

Patients with positive conversion within 12 months are considered acute cases and do not require concomitant clinical presentation for diagnosis.

Providers should test all pregnant people during each pregnancy, any person who requests hepatitis C testing, and offer hepatitis C testing to all adults aged 18 years and older at least once in their lifetime. Providers should also offer hepatitis C testing to people younger than 18 when there is evidence or indication of risk.

Providers should offer routine periodic hepatitis C testing based on potential for exposure:

• People with ongoing risk factors, including people who currently use or inject drugs and share needles, syringes, or other drug equipment
• Men who have sex with men, and transgender people who have sex with men
• People taking HIV PrEP
• People with certain medical conditions, including those who have ever received maintenance hemodialysis or peritoneal dialysis

Providers should order a serum hepatitis C antibody (Hep C Ab) test with reflex to hepatitis C RNA (HCV RNA or PCR) quantitative confirmatory test to assess the patient’s current hepatitis C infection status.

• If screening is conducted using point of care (rapid) test, testers should confirm a positive hepatitis C antibody result by ordering serum RNA testing or by performing a point of care qualitative RNA test.

Strategies to reduce time to diagnosis and treatment initiation:

• Collect all samples needed for hepatitis C diagnosis in a single visit and order HCV RNA reflex test (Hep C Ab reflex to PCR). Bonus: order reflex genotype test to be performed if HCV RNA is positive.
• If patient had hepatitis C in the past or a suspected exposure in the past 6 months, you may skip the Hep C Ab test and order HCV RNA test to assess current infection status.
• Implement point-of-care HCV RNA testing.
  • AASLD and Infectious Diseases Society of America (AASLD-IDSA) Hepatitis C Point-of-Care Test and Treat Algorithm (PDF, 2025)

Hepatitis C RNA Reflex Testing in NYC: Laboratories performing hepatitis C testing for New York City residents are required to use an automatic confirmatory hepatitis C viral test for all positive hepatitis C antibody results.

Additional testing guidance:

• NYS Requirements for Universal Hepatitis C Testing: Health Care Provider Fact Sheet (PDF, 2024)
• CDC: Recommended Testing Sequence for Identifying Current Hepatitis C Infection (PDF, 2013)
• CDC: Considerations for the Implementation of Point-of-Care Testing for the Diagnosis of Hepatitis C Virus Infection (PDF, 2024)
• CDC: Clinical Screening and Diagnosis for Hepatitis C

Hepatitis C can be cured in a few months in nearly all patients, including those who use drugs or who are co-infected with HIV or hepatitis B. Treating hepatitis C is easier with direct acting antivirals (DAAs). For more guidance, visit NYS Department of Health’s Hepatitis C Clinical Guidelines.

If the patient has hepatitis C, providers should provide treatment, as well as:

• Education on liver health management and how to prevent hepatitis C transmission and reinfection
• Vaccination for hepatitis A and B if there is no confirmation of immunity
• Assessment of liver function, chronic liver disease, and fibrosis score
• Screening for liver cancer in cases of advanced fibrosis/borderline cirrhosis and cirrhosis
• Guidance on long term health maintenance and recommended screenings post hepatitis C cure

Providers who cannot provide treatment to a patient with hepatitis C should refer the patient to a provider who treats hepatitis C.

Reinfection may occur in some people who continue to share drug-use equipment, share health care supplies including those for cosmetic procedures and gender affirming care, or otherwise remain at risk for infection.

Providers should:

• Test all adults once in their lifetime for hepatitis C infection
• Test people with ongoing risk factors annually
• Re-test people with new exposure or risk factor
• Re-treat people who are reinfected with hepatitis C to cure the new infection and to prevent transmission.
• Refer people who use drugs to harm reduction services to use drugs safely, prevent overdose and prevent blood borne infections and hepatitis C re-infection after cure. Find NYC harm reduction services and syringe service programs.

People with Hepatitis B and Hepatitis C Coinfection

All people with hepatitis C should be tested for hepatitis B, and vice versa. Hepatitis B and hepatitis C coinfection increases the risk of liver disease progression; therefore it is important to vaccinate for hepatitis B when immunity is lacking and to initiate treatment for both hepatitis B and hepatitis C when appropriate.

For people with hepatitis C who have an unknown hepatitis B status, testing for hepatitis B should be performed before or at the time of hepatitis C treatment initiation. Hepatitis B treatment should be initiated as close as possible to the start of hepatitis C treatment but hepatitis C treatment should not be delayed while waiting for hepatitis B test results. Hepatitis B should be addressed and managed even if treatment criteria for hepatitis B monoinfection are not met and should be continued for the duration of hepatitis C treatment.

People Who Use or Inject Drugs

Annual hepatitis C testing is recommended for people who use or inject drugs. If a person had hepatitis C in the past or a suspected exposure in the past 6 months, you may skip the antibody test and conduct a hepatitis C RNA test to assess current infection status. This can support early detection of hepatitis C infection or re-infection and prompt linkage to care and treatment.

Active or recent drug use or a concern for reinfection is not a contraindication to hepatitis C treatment. See AASLD recommendations for managing and treating hepatitis C among people who inject drugs.

People with HIV and Hepatitis C Coinfection

All people with HIV should be tested for hepatitis C. If positive, hepatitis C treatment should be prioritized to slow or prevent liver disease progression.

Many HIV antiretroviral therapies (ART) and hepatitis C direct acting antivirals (DAA) are safe when taken together. Providers should assess for drug-to-drug interactions between HIV ARTs and hepatitis C DAAs prior to initiating treatment. For recommended treatment regimens, visit NYS Department of Health AIDS Institute Treatment of Chronic Hepatitis C Virus Infection in Adults.

Pregnancy and Prevention of Infant and Child Transmission of Hepatitis C

Providers are required to test all pregnant people for hepatitis C during each pregnancy in New York State.

Providers should test for hepatitis C RNA in all infants and children born to pregnant people with current or probable hepatitis C. For more guidance, visit CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children (PDF, 2023).