Research Article

Performance of rapid tests for detection of HBsAg and anti-HBsAb

in a large cohort, France
Julie Bottero1,2,3,⇑, Anders Boyd1,3, , Joel Gozlan4, , Maud Lemoine5, Fabrice Carrat1,2,6,
Anne Collignon7, Nicolas Boo8, Philippe Dhotte9, Brigitte Varsat10, Gérard Muller11, Olivier Cha12,
Odile Picard3, Jean Nau13, Pauline Campa3, Benjamin Silbermann14, Marc Bary15,
Pierre-Marie Girard1,2,3, Karine Lacombe1,2,3
1
Inserm UMR-S707, Paris, France; 2Université Pierre et Marie Curie, Paris, France; 3AP-HP, Hôpital St Antoine, Service de Maladies Infectieuses,
Paris, France; 4AP-HP, Hôpital St Antoine, Laboratoire de Virologie, Paris, France; 5AP-HP, Hôpital St Antoine, Service d’Hépatologie, Paris, France;
6
AP-HP, Hôpital St Antoine, Unité de Santé Publique, Paris, France; 7Laboratoire de biologie médicale St Marcel, Paris, France; 8Direction de
l’Action Sociale, de l’Enfance et de la Santé (DASES), Paris, France; 9Centre de dépistage anonyme et gratuit (CDAG) du Figuier, Paris, France;
10
Département des Examens Périodiques de Santé (DEPS), CPAM de Paris, France; 11Centre de dépistage anonyme et gratuit (CDAG) de Belleville,
Paris, France; 12AP-HP, Hôpital St Antoine, Policlinique Baudelaire, Paris, France; 13Centre d’accueil, de soins et d’orientation, Médecin du Monde,
Paris, France; 14Unité de consultation et de soins ambulatoires (UCSA), Maison d’arrêt de la santé, Paris, France; 15Centre Croix Rouge du Moulin
Joly, Paris, France

Background & Aims: The systematic use of rapid tests performed inactive HBsAg carriers. The anti-HBsAb Quick Profile™ test had
at points-of-care may facilitate hepatitis B virus (HBV) screening excellent specificity (97.8%) and PPV (97.8%) albeit low sensitivity
and substantially increase HBV infection awareness. The aim of (58.3%), thus failing to establish non-inferiority.
this study was to evaluate the effectiveness of such tests for Conclusions: All three HBsAg rapid tests could be considered
HBsAg and anti-HBsAb detection among individuals visiting a ideal for HBV screening in low HBV-prevalent countries, given
variety of healthcare centers located in a low HBV-prevalent area. the ease of use, rapidity, and high classification probabilities.
Methods: Three rapid tests for hepatitis B surface antigen The anti-HBsAb Quick Profile™ could be considered reliable only
(HBsAg) detection (VIKIAÒ, Determine™ and Quick Profile™) for positive tests.
and one test for anti-hepatitis B surface antibody (anti-HBsAb) Ó 2012 European Association for the Study of the Liver. Published
detection (Quick Profile™) were evaluated in comparison to by Elsevier B.V. All rights reserved.
ELISA serology. Sensitivity (Se), specificity (Sp), positive and neg-
ative predictive values (PPV and NPV, respectively) and area
under the ROC curve were used to estimate test performance. Introduction
Non-inferiority criteria of the joint Se, Sp were set at 0.80, 0.95.
Results: Among the 3956 subjects screened, 85 (2.1%) were According to recent estimations, France has a low prevalence of
HBsAg-positive and 2225 (56.5%) had a protective anti-HBsAb chronic hepatitis B virus infection (CHB) as roughly 0.65% of those
titer. Test Se and Sp (lower bound of 97.5% CI) were as follows: cases with health insurance are estimated to be infected [1,2].
96.5% (89.0%), 99.9% (99.8%) for VikiaÒ; 93.6% (80.7%), 100.0% Although the social security system provides a wide range of ser-
(99.8%) for Determine™; and 90.5% (80.8%), 99.7% (99.5%) for vices targeted towards prevention and effective care, more than
Quick Profile™; with all three tests achieving minimal non- 280,000 people continue to live with chronic hepatitis B virus
inferiority criteria. False negatives were typically observed in infection, of whom over 55% are unaware of their infection-status
[1]. CHB diagnosis is therefore severely delayed in this group and
often occurs when severe clinical repercussions, such as advanced
Keywords: Hepatitis B; Rapid tests; Screening.
stages of cirrhosis and/or hepatocellular carcinoma, are already
Received 27 September 2012; received in revised form 31 October 2012; accepted 6 present. As a result, it is estimated that over 1300 deaths per year
November 2012; available online 23 November 2012 are directly attributable to hepatitis B virus (HBV) in France [3].
⇑ Corresponding author. Address: Service de Maladies Infectieuses, Hôpital St
Unawareness of HBV infection status could be explained by
Antoine, 184, rue du faubourg St Antoine, 75012 Paris, France. Tel.: +33 6 24 28 68
both the lack of knowledge among those at risk (i.e., subjects born
73; fax: +33 01 49 28 21 49.
E-mail address: [email protected] (J. Bottero). in geographic regions with hepatitis B surface antigen (HBsAg)
 
These authors contributed equally to this work. prevalence >2%, household contacts, sexual partners of subjects
Abbreviations: CHB, chronic hepatitis B; HBV, hepatitis B virus; HBsAg, hepatitis B with CHB or intravenous drug users [4]) and the lack of recogni-
surface antigen; Anti-HBsAb, anti-HBs antibody; Anti-HBsAc, anti-hepatitis B core tion concerning the seriousness of its public health impact among
antibody; ELISA, enzyme-linked immuno-assay; Se, sensitivity; Sp, specificity;
general practitioners. Furthermore, the absence of national guide-
PPV, positive predictive value; NPV, negative predictive value; LR+, positive lik-
elihood ratio; LR, negative likelihood ratio; AUROCs, area under the receiving lines related to screening practices leads to further confusion,
operator curve; FPF, false positive fraction; TPF, true positive fraction. with highly variable screening protocols between healthcare

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Research Article
centers. In order to remedy this inadequacy, the ‘‘National Hepa-
titis Plan, 2009–2012’’ [5] recommended increasing HBV screen- VIKIA® , Biomerieux
ing and improving consistent reporting. One public health tool
that could potentially drive such an increase is the use of rapid
tests, which may facilitate access to screening services.
Until recently (2012), no HBV rapid test has been approved for
use by European or North American regulatory agencies. More-
over, there have been very few studies validating their use in
low HBV-prevalent countries, apart from those given by the tests’
manufacturers, in which their performance has been mainly eval-
uated on serum samples rather than on whole blood specimens.
We then aimed at conducting a multicenter, cross-sectional, sin-
gle-arm evaluation of several rapid tests that could be used to
identify the presence of serological markers typically used in
DetermineTM , Quick ProfileTM ,
screening for CHB infection.
Inverness Biomedical Innovations Lumiquick

Fig. 1. Picture of the 3 rapid tests. (This figure appears in color on the web.)
Patients and methods

Study participants number of 5 clinic research associates). Only results that the two readers agreed
upon were included. However, if one reading was indeterminate while the other
was definitive, the definitive reading was taken as the final result.
From September 2010 to August 2011, 4000 subjects were recruited from ten,
Paris-based healthcare centers whose aims involved screening, prevention and/
or vaccination of diverse populations. Inclusion criteria for the present study were Statistical analysis
as follows: agreement to be screened for HBV, 18 years of age or older, and avail-
ability for a subsequent follow-up questionnaire via telephone. Participants with- Rapid tests were compared to ELISA, which served as the gold standard. Sensitiv-
out health coverage were also included [5]. All participants provided written ity (Se), specificity (Sp), positive and negative predictive value (PPV and NPV,
informed consent and the protocol was approved by the Hôtel-Dieu Hospital Eth- respectively), positive and negative likelihood ratio (LR+ and LR, respectively)
ics Committee (Paris, France) in accordance with the Helsinki Declaration. were estimated. Area under the ROC curves (AUROCs) were also calculated and
compared between rapid tests using a test of equality of ROC areas. Inter-rater
Rapid test comparisons and gold standard agreement was determined using the Kappa statistic, without taking into account
indeterminate results.
Using a previously described method [7], we powered the study in order to
Approximately 10 ml of whole blood was collected into a tube without any addi-
test desirable levels of the pair [false positive fraction (FPF), true positive fraction
tive from each participant. Before the blood had yet to coagulate, a few drops
(TPF)] at (0.02, 0.95). Non-inferiority criteria were then selected with minimally
were immediately removed from the sample and used for each rapid test accord-
acceptable (FPF, TPF) at (0.05, 0.80), reflecting the importance of decreasing the
ing to manufacturers’ instructions. Anticoagulant was not added to the sample
number of false positives while increasing the number of cases identified [8].
because only serum was required for subsequent study procedures. Three tests
We aimed at testing a one-sided, null hypothesis assuming a joint power of
for HBsAg detection (VIKIAÒ, Biomerieux, Marcy-l’Étoile, France; Determine™,
0.90 and type I error (a) of 0.05. After accounting for an estimated prevalence
Inverness Biomedical Innovations, Köln, Germany; Quick Profile™, Lumiquick,
of 2.0% from previous population-based studies within Paris [1] and correcting
Santa Clara, CA, USA) and one test for anti-HBs antibody (anti-HBsAb) detection
calculations on a 90% probability that the sample obtained will be at least as large
(Quick Profile™, Lumiquick) were evaluated (Fig 1). These qualitative tests are
as required, the minimum number of participants needed was 3384 and 489 (for
based on the principle of immunochromatography, in which membrane chroma-
enough diseased and non-diseased subjects, respectively). As both FPF and TPF
tography is used to determine the presence of polyclonal antibodies specific for
are considered,
pffiffiffiffiffiffiffiffiffiffiffiffi pffiffiffiffiffiffiffiffiffiffi the joint 95% confidence region is given from the 97.5%
HBsAg or anti-HBs antibody within a test region. In order to determine partici-
( 1  a ¼ 95%) univariate intervals. For ease in clinical interpretation, we
pants’ ‘‘true’’ HBV status, serum was processed from whole blood and tested using
report the sensitivity (TPF) and specificity (1-FPF). Statistical analyses were per-
a commercially-available enzyme-linked immuno-assay (ELISA) (MONOLISA
formed using STATA (v11.2, College Station, TX, USA) statistical software.
AgHBS Ultra, anti-HBs plus, anti-hepatitis B core antibody-anti-HBc-plus, BIO-
RAD, Hercules, USA). Only results of this testing were relayed to participants
and their general practitioner. All participants found to have active HBV infection
were asked if they would like to schedule a medical visit, during which a com- Results
plete evaluation would be performed at a specialized clinic and therapy options
would be discussed, if necessary. Additionally, all HBsAg-positive specimens
Study participants
had HBsAg quantification done using the ARCHITECT HBsAg enzyme-linked
immunoassay (Abbott Laboratories, Rungis, France), and HBV DNA quantification,
using the commercial quantitative polymerase chain reaction assay COBAS Taq- At the end of the study, a total of 3956 subjects had at least one HBV
man 48 HBV (Roche Diagnostic Systems, Meylan, France). For one specimen, rapid test with ELISA results and were hence included in the anal-
HBV sequencing was performed on the pol/S region, as previously described [6]. ysis. As discordant inter-rater results were excluded and
The sequence was analyzed with the ‘‘HBV tool’’ accessible online at http://
www.hiv-grade.de/cms/grade/hbv-tool.html.
the HBsAg Determine™ test was not available at the beginning of
the study, but rather six months later, the number of participants
Quality control of rapid tests varied among rapid tests (VIKIAÒ, N = 3928; Quick Profile™ HBsAg
test, N = 3922, anti-HBsAb test, N = 3739; Determine™, N = 2472).
Rapid tests were performed immediately after the participant’s sample was taken
and in the same room as where blood collection occurred. Staff noted the date HBsAg rapid tests
and time at which all tests were performed. Each rapid test had a control indicat-
ing whether the sample sufficiently migrated along the membrane (i.e., the test
Operator success and indeterminate results
was performed correctly). In the event of an invalid test, two other attempts were
made at most in order to achieve a valid result. Valid test results were then read Successful results were obtained on first attempt for the majority
within 30 min by two independent, previously-trained staff members (for a total of rapid tests (VikiaÒ: 99.8%; Determine™: 100%; Quick Profile™:

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 JOURNAL OF HEPATOLOGY
Table 1. Classification probabilities comparing rapid HBsAg tests compared to ELISA.

HBsAg serology ELISA AUC (95% CI) Se Sp PPV NPV LR+ LR-
Positive Negative
VIKIA® (n = 85) (n = 3843) 0.982 (0.962-1.000) 96.5 99.9 97.6 99.9 1854 0.04
Positive 82 2
Negative 3 3841
DETERMINETM (n = 47) (n = 2425) 0.968 (0.933-1.000) 93.6 100.0 100.0 99.9 ∞ 0.06
Positive 44 0
Negative 3 2425
QUICK PROFILETM (n = 84) (n = 3838) 0.951 (0.919-0.983) 90.5 99.7 88.4 99.8 347 0.10
Positive 76 10
Negative 8 3828
HBsAg, hepatitis B surface antigen; ELISA, enzyme-linked immuno-assay; AUC, area under the curve; Se, sensitivity; Sp, specificity; PPV, positive predictive value; NPV,
negative predictive value; LR+, positive likelihood ratio; LR-, negative likelihood ratio.

98.1%). For 6 VikiaÒ results considered as final in the analysis, one given for all false negative tests in Table 2. Median HBsAg levels
reader gave an indeterminate result and the other a negative one were significantly lower in patients with false negative versus
(all patients with HBsAg-negative serology). Of 5 final Deter- true positive tests (19.5 vs. 2351.0 IU/ml, p = 0.0001) and only 4
mine™ test results, 4 had one indeterminate and one negative false negative tests had HBsAg >10 IU/ml (Determine™, n = 1;
reading (3 with HBsAg-negative and 1 with HBsAg-positive serol- Quick Profile™, n = 3). Likewise, HBV-DNA levels were almost
ogy), while 1 was determined from one indeterminate and one all below 200 IU/ml, with the exception of one patient, with a
positive reading (HBsAg-serology positive). Finally, 11 final Quick false negative Quick Profile™, who had a HBV viral load at
Profile™ test results were obtained with at least one indetermi- 884 IU/ml, and one patient with a false negative Determine™
nate reading: 10 with the other reading being negative (all having test, with a HBV viral load at 1.02 106 IU/ml, and three positive
HBsAg-negative serology) and 1 with the other reading being serological markers (HBsAg+, anti-HBcAb, anti-HBsAb = 43 IU/l).
positive (HBsAg-negative serology). HBV from this last specimen was sequenced in the HBV S gene
and displayed the typical G145R immune escape mutation. Inter-
Inter-rater discrepancies estingly, only two participants had false negative results for all
Overall, between-rater agreement was high for the VikiaÒ, Deter- three rapid tests (although patient number I-2-124, who had
mine™, and Quick Profile™ HBsAg tests (r = 1.00, 0.95, 0.98, two false negative rapid tests, did not have an available Deter-
respectively). There were no inter-rater disagreements using mine™ rapid test). Two subjects had false positive tests (n = 2,
the VikiaÒ test. A total of 4 inter-rater disagreements were non-immunized) with the VIKIAÒ and 10 subjects (vaccinated,
observed with the Determine™ test, of which 3 were found in n = 7; non-immunized, n = 2; resolved HBV infection with anti-
non-immunized participants and one in a person with resolved HBsAb titer at 51 IU/l, n = 1) with the Quick Profile™ test. No false
HBV infection. Finally, 3 inter-rater disagreements were found positive tests were observed using the Determine™ test (Table 1).
with the Quick Profile™ test, of which 2 were among vaccinated
participants and 1 in a non-immunized person. Anti-HBsAb rapid test

Diagnostic accuracy Operator success and indeterminate tests

As shown in Table 1, every rapid test had excellent specificity for Reliable results were obtained for 97.6% of the anti-HBsAb Quick
HBsAg detection, all with values above 99.0%. Sensitivity ranged Profile™ tests on first attempt. A total of 278 final results were
between 90.5% for the Quick Profile™ and 96.5% for the VikiaÒ given by a mix of one indeterminate reading and one definitive
tests. All three tests had achieved minimal non-inferiority crite- reading (one concomitant anti-HBsAb positive reading, n = 115;
ria, with the lower 97.5% confidence interval of Se and Sp, respec- one concomitant anti-HBsAg negative reading, n = 163).
tively, as follows: 89.0% and 99.8% for the VikiaÒ test, 80.7% and
99.8% for the Determine™ test, 80.8% and 99.5% for the Quick Inter-rater discrepancies
Profile™ test. Only the AUROC for the Quick Profile™ was signif- Between-rater agreement of the anti-HBsAb Quick Profile™ was
icantly different (p = 0.002) when compared to the gold standard lower compared to HBsAg rapid tests (r = 0.94). A total of 99 tests
(AUROC = 1.0) (p = 0.08 for both the VikiaÒ and Determine™ (2.5% of the available 3900 original tests) had discordant
tests). Furthermore, there was a significant difference in AUROC readings.
when comparing the VikiaÒ and Quick Profile™ rapid tests
(p = 0.02), but not between VikiaÒ and Determine™ (p = 0.3) or Diagnostic accuracy
Quick Profile™ and Determine™, (p = 0.2). In the study population, the anti-HBsAb Quick Profile™ test had
low sensitivity (58.3%), but high specificity (97.8%). As shown in
Discordant results Table 3, predictive values were very different, with high PPV
There were a total of 14 false negative results: 3 with VIKIAÒ, 3 and low NPV. Non-inferiority could not be ascertained as the null
with Determine™, and 8 with the Quick Profile™ test. Details hypothesis could not be rejected for the anti-HBsAb Quick Pro-
on rapid test results along with full ELISA battery, HBsAg quanti- file™ test, with lower 97.5% CI of sensitivity and specificity at
fication, HBV-DNA viral load, and HBV-related clinical status are 55.8% and 96.9%, respectively. Furthermore, the AUROC curve

Journal of Hepatology 2013 vol. 58 j 473–478 475

Research Article
Table 2. Participants with false negative results (between HBsAg rapid tests and ELISA).

Participant ELISA HBsAg HBsAg HBsAb HBV viral Hepatitis B clinical status*
rapid test titer titer load
HBsAg HBsAb HBcAb Reader 1 Reader 2 (IU/ml) (IU/ml) (IU/ml)
VIKIA®
I-2-124 + - + - - 5 <8 <12 Inactive carrier
I-2-309 + - + - - 2.3 <8 143 Lost to follow-up
I-8-272 + - + - - 5 <8 62 Inactive carrier
DETERMINETM
I-2-309 + - + - - 2.3 <8 143 Lost to follow-up
I-7-14 + + + ? - 90 43 >106 Active hepatitis B
I-8-272 + - + - - 5 <8 62 Inactive carrier
QUICK PROFILETM
I-2-124 + - + - - 5 <8 <12 Inactive carrier
I-2-245 + - + - - 50 <8 137 Inactive carrier
I-2-309 + - + - - 2.3 <8 143 Lost to follow-up
I-2-315 + - + - - 5226 <8 18 Inactive carrier
I-2-514 + - + - - 4.7 <8 48 Inactive carrier
I-6-36 + - + - - 7.4 <8 <12 Inactive hepatitis B with
advanced fibrosis
I-8-272 + - + - - 5 <8 62 Inactive carrier
I-8-368 + - + - - 304.7 <8 884 Inactive carrier; resolved
HCV co-infection
HBsAg, hepatitis B surface antigen; HBsAb, anti-hepatitis B surface antibodies; HBcAb, anti-hepatitis B core antibodies; ELISA, enzyme-linked immuno-assay; HBV, hepatitis
B virus; HCV, hepatitis C virus; UI/ml, international unit per milliliter.
⁄
Determined from guidelines developed by the European Association for the Study of the Liver (EASL) [12].

Table 3. Classification probabilities comparing the rapid anti-HBs antibody test compared to ELISA.

Anti-HBsAb serology AUC (95% CI) Se Sp PPV NPV LR+ LR-

Positive Negative
QUICK PROFILETM (n = 2091) (n = 1648) 0.781 (0.769-0.792) 58.3 97.8 97.1 64.9 26.7 0.43
Positive 1219 36
Negative 872 1612
Anti-HBsAb, anti-hepatitis B surface antibodies; ELISA, enzyme-linked immuno-assay; AUC, area under the curve; Se, sensitivity; Sp, specificity; PPV, positive predictive
value; NPV, negative predictive value; LR+, positive likelihood ratio; LR-, negative likelihood ratio.

was significantly lower when compared to the gold standard ELISA. On the contrary, the anti-HBsAb test by Quick Profile™
(p <0.0001). would require further refinement in its sensitivity, albeit specific-
ity was rather high.
Discordant results In comparison with previous evaluations of HBV rapid tests,
A total of 36 (1.0%) false positive and 872 (23.3%) false negative this study presents several advantages. First, unlike the study
tests were identified with the anti-HBsAb Quick Profile™. Median populations from most previous research, our catchment area
anti-HBsAb titer of those with a false negative anti-HBsAb Quick was established in a low HBV-prevalent country, while including
Profile™ test was 58 IU/l (IQR: 24-157, min 10, max 1000). Fur- a large sample, representative of those likely to be screened.
thermore, 69.6% of participants with false negative tests had been Second, test effectiveness was the major focus in the sense that
previously vaccinated. rapid tests were carried out in settings outside of a specialized
laboratory, using whole blood specimens that were imme-
diately assayed after participants’ blood draw. Finally, since most
HBsAg-positive patients were followed at one specialized center,
Discussion the clinical features of those with false negative rapid tests could
be clarified in full detail.
While many HBV rapid tests are distributed worldwide, very few Notwithstanding these differences, we observed similar clas-
are available in Europe. After an extensive search of companies sification probabilities compared to previous reports mainly from
allowing Phase IV evaluation of their rapid tests, three were the Determine™ rapid test. All of these studies were conducted in
finally included in our study. All three HBsAg rapid tests, VikiaÒ, high HBsAg-prevalent countries (sensitivity between 94.4% and
Determine™, and Quick Profile™, met non-inferiority criteria and 98.9% and specificity between 99.4% and 100%) [9–11]. Only
were highly accurate in predicting HBsAg status as determined by one previous study has evaluated the effectiveness of the VIKIAÒ

476 Journal of Hepatology 2013 vol. 58 j 473–478

 JOURNAL OF HEPATOLOGY
rapid test in Ghana among HIV-infected patients, giving a dra- contrast, 2.5% of the anti-HBsAb rapid tests had this result pat-
matically lower sensitivity (70.7%) but high specificity (100%) tern. A systematic double reading procedure is probably not
[12]. For the moment, it is unclear why such a large gap in sensi- required for any of the rapid tests presented in our study.
tivity was observed, considering that most HBsAg-positive study To overcome this issue, it would be recommended that
participants originated from a country of high HBV endemicity. It another trained reader blindly confirmed indeterminate results.
should be noted that the Determine™ test also had very low sen- In conclusion, given the ease of use, rapidity, and high classi-
sitivity in this study (69.3%). Finally, no previous study, aside fication probabilities, the HBsAg tests evaluated in this study
from the one reported by the manufacturer, has been docu- should be considered ideal for HBV screening, particularly among
mented for the Quick Profile™ test. Taken together, we consider institutions in which patients are frequently lost to follow-up or
our results as providing the most conclusive information to date where testing via ELISA is not readily available. Although a posi-
regarding the effectiveness of these rapid tests for use in low- tive anti-HBsAb test would be reliable, it would be difficult to
prevalent countries. determine if an individual was previously exposed to HBV or vac-
False negative results were very low across all three HBsAg cinated with a negative result. As was the case for HIV [21,22],
rapid tests. With the VIKIAÒ test, false negatives were only these tests could allow accurate and potentially increased aware-
observed among inactive carriers, as defined by the European ness of HBV status in a variety of settings, such as persons in
Association for the Study of the Liver (EASL) [13]; whereas all socially-marginalized situations. More data on the medical-
patients with active CHB requiring monitoring and/or treatment economic impact of including rapid tests is needed, especially
were accurately detected. The same was true for both Deter- in low-prevalent countries with abundant financial resources
mine™ and Quick Profile™ tests, however certain exceptions but limited systematic screening.
were certainly noted. Using the Quick Profile test, one HBsAg-
positive patient with advanced fibrosis and another with high
levels of quantified HBsAg levels were incorrectly classified as Financial support
HBsAg-negative. Even though both these patients were clinically
inactive carriers, some research has suggested these additional From the Agence Nationale de Recherches sur le Sida et les hépa-
characteristics may qualify them as having active chronic HBV tites virales (Grant No. 2010-334), Gilead Sciences and Roche.
[14,15]. Since inactive carriers continue to be at risk of develop-
ing hepatocellular carcinoma [16], other ways of ensuring their
correct detection may need further investigation.
Conflict of interest
The Determine™ test failed to detect one HBsAg-positive
patient (1-7-14) with high HBV viral load and an uncommon
The authors who have taken part in this study declared that they
serological profile (positive for HBsAg, anti-HBsAb and anti-
do not have anything to disclose regarding funding or conflict of
HBcAb). Interestingly, this patient was infected with an immune
interest with respect to this manuscript.
escape variant of HBV, with the G145R mutation in the S gene
sequence. This variant has been associated with both concomi-
tant positivity for HBsAg and anti-HBsAb [17] and reduction of Acknowledgments
antigenicity and immunogenicity (inability to recognize HBsAg
by some diagnostic tests) [18–20]. Without knowing the individ- We wish to thank all study participants as well as all medical and
ual components of each test, it cannot be clearly established why paramedical centers participating in the study and the data man-
the VIKIAÒ and Quick Profile™ tests were positive for this partic- agement center especially F. Chau, F. Fotre, I. Goderel and G.
ular patient. Pannetier. We also acknowledge Samia Hicham, Judith Leblanc,
Unfortunately, we could not obtain HBV genetic information Manuela Sebire and Farid Djoumad for their extraordinary effort
on the other false negative HBsAg-positive participants, mainly in data collection at the various sites and, in particular, Hayette
because they were either non-replicative or had very low viral Rougier for study co-ordination.
loads (Table 2). This information would have allowed us to deter- This study was made possible by funds from the Agence Natio-
mine if some of these false negative results were also due to nale de Recherches sur le Sida et les hépatites virales (Grant
amino acid variability on the HBsAg ‘‘a’’ antigenic region. How- No. 2010-334), Gilead Sciences and Roche and material support
ever, all but one of these patients (1-2-315) had very low levels from the Mairie de Paris. We also would like to sincerely thank
of serum HBsAg, strongly suggesting that relative lack of rapid rapid test producers who have accepted this assessment and
test sensitivity at low HBsAg levels was the main reason for false provided us with their tests on preferential terms (free for
negatives rather than from mutations on the HBs ‘‘a’’ epitope. Biomerieux).
Regarding rapid anti-HBs Ab detection, this is the first study
evaluating the performance of such test to our knowledge. We
observed a low sensitivity (regardless of anti-HBsAb titers) but Addendum
excellent specificity, while at the same time NPV was poor and
PPV very good. Therefore, it would be recommended that HBsAb The OPTISCREEN-B study group:
Quick Profile™ results were considered reliable only in cases Coordinating center: PM Girard, K Lacombe, J Bottero, H Rou-
where the test is positive. gier, S Hicham, J Leblanc, M Sebire, F Djoumad. Scientific advis-
One limitation of our study was that we counted test results ors: M Lemoine, J Gozlan, A Boyd. Data management center: F
with one determinate and one indeterminate reading as confir- Carrat, F Chau, F Fotre, I. Goderel and G. Pannetier.
matory. This phenomenon was rarely observed and, when so, The participating clinical site investigators are as follows: O
occurred predominately among HBsAg-negative patients. In Picard (CDAG Saint-Antoine Hospital), N Boo, G Muller, P Dhotte

Journal of Hepatology 2013 vol. 58 j 473–478 477

Research Article
(CDAG Ville de Paris), V Matharan (Centre de Santé au Maire- [10] Lin YH, Wang Y, Loua A, Day GJ, Qiu Y, Nadala Jr EC, et al. Evaluation of a new
Volta), B Varsat, G Delord (Département des Examens Périodiques hepatitis B virus surface antigen rapid test with improved sensitivity. J Clin
Microbiol 2008;46:3319–3324.
de Santé, DEPS,CPAM de Paris), P Cazaux (DEPS, Stalingrad site), [11] Randrianirina F, Carod JF, Ratsima E, Chretien JB, Richard V, Talarmin A.
(Centre d’examen de santé de l’Adulte de la CPAM de Paris, Stalin- Evaluation of the performance of four rapid tests for detection of hepatitis B
grad site), M Bary (Centre de la Croix Rouge Moulin Joly), MD surface antigen in Antananarivo, Madagascar. J Virol Methods 2008;151:
Pauti, J Nau (Centre de Médecins du Monde, CASO), J Lebas, V Vas- 294–297.
[12] Geretti AM, Patel M, Sarfo FS, Chadwick D, Verheyen J, Fraune M, et al.
seur, O Cha (Policlinique Saint-Antoine Hospital), P Campa (Con-
Detection of highly prevalent hepatitis B virus coinfection among HIV-
sultation Voyageurs Saint-Antoine Hospital), B Silbermann seropositive persons in Ghana. J Clin Microbiol 2010;48:3223–3230.
(UCSA), A Collignon (Laboratoire Saint-Marcel). [13] Pawlotsky JM. EASL clinical practice guidelines. J Hepatol 2009;50:243.
[14] Maimone S, Calvaruso V, Pleguezuelo M, Squadrito G, Amaddeo G, Jacobs M,
et al. An evaluation of transient elastography in the discrimination of
References HBeAg-negative disease from inactive hepatitis B carriers. J Viral Hepat
2009;16:769–774.
[1] Meffre C, Le Strat Y, Delarocque-Astagneau E, Antona D, Desenclos JC. [15] Brunetto MR, Oliveri F, Colombatto P, Moriconi F, Ciccorossi P, Coco B, et al.
Prévalence des hépatites B et C en France en 2004; 2006. http:// Hepatitis B surface antigen serum levels help to distinguish active from
www.invs.sante.fr/publications/2006/prevalence_b_c/index.htm. inactive hepatitis B virus genotype D carriers. Gastroenterology 2010;139:
[2] WHO. Hepatitis B: World Health Organization Fact Sheet 204; 2008. http:// 483–490.
www.who.int/mediacentre/factsheets/fs204/en/. [16] Chen JD, Yang HI, Iloeje UH, You SL, Lu SN, Wang LY, et al. Carriers of inactive
[3] Marcellin P, Pequignot F, Delarocque-Astagneau E, Zarski JP, Ganne N, Hillon hepatitis B virus are still at risk for hepatocellular carcinoma and liver-
P, et al. Mortality related to chronic hepatitis B and chronic hepatitis C in related death. Gastroenterology 2010;138:1747–1754.
France. Evidence for the role of HIV coinfection and alcohol consumption. J [17] Lada O, Benhamou Y, Poynard T, Thibault V. Coexistence of hepatitis B
Hepatol 2008;48:200–207. surface antigen (HBs Ag) and anti-HBs antibodies in chronic hepatitis B virus
[4] Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, et al. carriers: influence of ‘‘a’’ determinant variants. J Virol 2006;80:2968–2975.
Recommendations for identification and public health management of [18] Carman WF, Zanetti AR, Karayiannis P, Waters J, Manzillo G, Tanzi E, et al.
persons with chronic hepatitis B virus infection. MMWR Recomm Rep Vaccine-induced escape mutant of hepatitis B virus. Lancet 1990;336:
2008;57:1–20. 325–329.
[5] DGS. Plan national de lutte contre les hépatites B et C (2009-2012). 2009. [19] Tian Y, Xu Y, Zhang Z, Meng Z, Qin L, Lu M, et al. The amino acid residues at
http://www.sante-sports.gouv.fr/IMG/pdf/Plan_hepatites_2009_2012.pdf. positions 120 to 123 are crucial for the antigenicity of hepatitis B surface
[6] Villeneuve JP, Durantel D, Durantel S, Westland C, Xiong S, Brosgart CL, et al. antigen. J Clin Microbiol 2007;45:2971–2978.
Selection of a hepatitis B virus strain resistant to adefovir in a liver [20] Weber B. Diagnostic impact of the genetic variability of the hepatitis B virus
transplantation patient. J Hepatol 2003;39:1085–1089. surface antigen gene. J Med Virol 2006;78:S59–S65.
[7] Pepe MS. The statistical evaluation of medical tests for classification and [21] Hutchinson AB, Branson BM, Kim A, Farnham PG. A meta-analysis of the
prediction. Oxford, United Kingdom: Oxford University Press; 2003. effectiveness of alternative HIV counseling and testing methods to increase
[8] Morrison A. Screening for chronic diseases. Oxford University Press; 1992. knowledge of HIV status. AIDS 2006;20:1597–1604.
[9] WHO. Hepatitis B surface antigen assays: operational characteristics (phase [22] Thornton A, Delpech V, Kall M, Nardone A. HIV testing in community
I). Blood safety and clinical technology. WHO: Geneva, Switzerland; 2001. settings in resource-rich countries: a systematic review of the evidence. HIV
www.who.int/diagnostics_laboratory/evaluations/en/hep_B_rep1.pdf. Med 2012.

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