Hepatitis B virus in transfusion medicine: still a problem?

Hepatitis B virus (HBV) has probably evolved with humans for nearly 35,000 years. HBV diversified into 9 genotypes (A-I) presenting specific features directing epidemiology, clinical expression and testing. Genotypes E and C are more infectious and carry higher risk of chronicity and cancer. HBsAg blood screening implemented 40 years ago enormously decreased the risk of transfusion transmission but the remaining risk requires extremely sensitive nucleic acid testing (NAT) to be removed. Limitations of the host immune system, the impact of immunodeficiency and the mechanisms utilised for viral persistence were recently identified. HBV replication produces excess HBsAg and infectious and defective viral particles but screening assays for HBsAg or viral particles alone do not allow fully efficient detection, making necessary screening for both. The host immune system fails to completely control the virus that escapes and persists unrecognized at very low levels or as immuno-selected variants. Variants may not be identified by assays, explaining false negative results. Specific mutations may affect post-transcriptional mechanisms including HBV RNA splicing. Asymptomatic HBV infected blood donors are at risk of long-term complications through mechanisms to be understood for appropriate counselling. Infectivity of occult HBV infection (OBI) by transfusion appears low, anti-HBc (anti-core antigen) only being more infectious than anti-HBs (anti-S protein) positive units.