Use of Nucleic Acid Tests to 
Reduce the Risk of 
Transmission of Hepatitis B 
Virus from Donors of Human 
Cells, Tissues, and Cellular 
and Tissue-Based Products 
 
 
Guidance for Industry 
 
 
 
 
 
 
 
Additional copies of this guidance are available from the Office of Communication, Outreach 
and Development (OCOD), 10903 New Hampshire Ave., Bldg. 71, Rm. 3128, Silver Spring, 
MD 20993-0002, or by calling 1-800-835-4709 or 240-402-8010, or email ocod@fda.hhs.gov, or 
from the Internet at 
http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guida
nces/default.htm. 
 
For questions on the content of this guidance, contact OCOD at the phone numbers or email 
address listed above. 
 
 
 
U.S. Department of Health and Human Services 
Food and Drug Administration 
Center for Biologics Evaluation and Research 
August 2016  Contains Nonbinding Recommendations 
 
Table of Contents 
 
 
I.  INTRODUCTION............................................................................................................. 1 
II.  BACKGROUND ............................................................................................................... 2 
A.  HBV Epidemiology and Public Health Impact .................................................. 2 
B.  Rationale for HCT/P Donor Testing Using HBV NAT ..................................... 3 
III.  RECOMMENDATIONS .................................................................................................. 4 
IV.  IMPLEMENTATION ...................................................................................................... 4 
V.  REFERENCES .................................................................................................................. 5 
i  Contains Nonbinding Recommendations 
 
Use of Nucleic Acid Tests to Reduce the Risk of Transmission of 
Hepatitis B Virus from Donors of Human Cells, Tissues, and 
Cellular and Tissue-Based Products 
 
 
Guidance for Industry 
 
 
This guidance represents the current thinking of the Food and Drug Administration (FDA or 
Agency) on this topic.  It does not establish any rights for any person and is not binding on FDA 
or the public.  You can use an alternative approach if it satisfies the requirements of the 
applicable statutes and regulations.  To discuss an alternative approach, contact the FDA staff 
responsible for this guidance as listed on the title page. 
 
 
I.  INTRODUCTION 
 
We, FDA, are providing you, establishments that make donor eligibility determinations for 
donors of human cells, tissues, and cellular and tissue-based products (HCT/Ps), with 
recommendations concerning the use of FDA-licensed nucleic acid tests (NAT) in donor testing 
for hepatitis B virus (HBV) deoxyribonucleic acid (DNA).  We consider the use of FDA-licensed 
HBV NAT in testing HCT/P donors to be necessary to adequately and appropriately reduce the 
risk of transmission of HBV.  The FDA-licensed HBV NAT can detect evidence of the viral 
infection at an earlier stage than the hepatitis B surface antigen (HBsAg) and total antibody to 
hepatitis B core antigen (anti-HBc) tests.  Therefore, we recommend the use of FDA-licensed 
HBV NAT, in addition to the use of licensed HBsAg and total anti-HBc Immunoglobulin G 
(IgG) and Immunoglobulin M (IgM), for testing donors of HCT/Ps for evidence of infection with 
HBV.1  This guidance finalizes the draft guidance of the same title dated January 2016 and 
supplements previous recommendations from FDA to HCT/P establishments concerning donor 
testing for HBsAg and total anti-HBc, in the document entitled Guidance for Industry:  
Eligibility Determination for Donors of Human Cells, Tissues, and Cellular and Tissue-Based 
Products (HCT/Ps) dated August 2007 (2007 Donor Eligibility Guidance) (Ref. 1). 
 
FDAs guidance documents, including this guidance, do not establish legally enforceable 
responsibilities.  Instead, guidances describe the FDAs current thinking on a topic and should be 
viewed only as recommendations, unless specific regulatory or statutory requirements are cited.  
The use of the word should in FDAs guidances means that something is suggested or 
recommended, but not required. 
 
 
                                                 
1 FDA licensed donor screening tests can be found via the following link: 
http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/TissueSafety/ucm095440.htm. 
1  Contains Nonbinding Recommendations 
 
II.  BACKGROUND 
 
HBV is a relevant communicable disease agent or disease (RCDAD) according to  
21 CFR 1271.3(r).  Section 1271.75 requires screening, and 21 CFR 1271.80 and  
21 CFR 1271.85 require testing for HBV to adequately and appropriately reduce the risk of 
transmission of this RCDAD.  The 2007 Donor Eligibility Guidance recommends that HCT/P 
donors be tested for HBsAg and total anti-HBc (IgG and IgM) (Ref. 1).  The 2007 Donor 
Eligibility Guidance also indicated that the FDA recommendations on specific tests may change 
in the future due to technological advances or evolving scientific knowledge.   
 
A.  HBV Epidemiology and Public Health Impact 
 
HBV is a major global public health concern.  According to the World Health 
Organization (WHO), there are 240 million people who are chronically infected with 
HBV.  Approximately 686,000 persons die each year from HBV infections worldwide.  
Regional prevalence is highest in sub-Saharan Africa and East Asia, where between 5-
10% of the adult population is chronically infected.  Less than 1% of the population in 
Western Europe and North America is chronically infected (Refs. 2, 3).  In 2013, in the 
United States, there were 3,050 cases of acute hepatitis B reported from 48 states to 
Centers for Disease Control and Prevention (CDC).  The overall incidence rate for 2013 
was 1.0 case per 100,000 population.  After adjusting for under-ascertainment and under-
reporting, an estimated 19,764 acute hepatitis B cases occurred in 2013.  Additionally, it 
is estimated that there are between 700,000 to 1.4 million persons infected with HBV in 
the United States, many of whom are unaware of their infection status (Ref. 4). 
 
The clinical course of HBV infection is determined by the balance between virus 
replication and the hosts immune response.  Most primary infections in adults are self-
limited.  The virus is cleared from blood and liver, and individuals develop a lasting 
immunity.  However, HBV may persist in the body even after serological recovery from 
acute HBV infection.  Chronic HBV infection after acute exposure can be serious and 
may depend on the age of the individual at the time of primary infection.  About 1% to 
3% of infected adults develop chronic infections that can be asymptomatic (i.e., a carrier 
state, a chronically infected individual that is able to spread the disease to others).  
Between 30% and 90% of infants and young children (< 5 years of age) infected with 
HBV develop chronic hepatitis.  By comparison, only 2% to 10% of children older than 5 
years of age infected with HBV develop chronic hepatitis (Ref. 5).   
 
Potential sequelae of HBV infection include acute and chronic hepatitis, cirrhosis, and 
hepatocellular carcinoma.  About 20% of chronically infected individuals develop 
cirrhosis.  Chronically HBV infected subjects have 100 times higher risk of developing 
hepatocellular carcinoma than non-carriers (Ref. 6).  It has been shown that HBV 
infection can occur in previously vaccinated individuals who are exposed to a different 
HBV genotype (Ref. 7).   
 
 
2  Contains Nonbinding Recommendations 
 
B.  Rationale for HCT/P Donor Testing Using HBV NAT 
 
HBV is transmitted by blood transfusions more frequently than hepatitis C virus (HCV) 
or human immunodeficiency virus (HIV).  HBV NAT is a more sensitive technology 
which could detect trace amounts of HBV DNA during the window period in HBsAg 
negative blood specimens (i.e., a potential reduction of the infectious window period of 
up to 40 days depending on sensitivity of the HBsAg test) (Ref. 2).  In blood donors, 
adding HBV NAT testing for HBV reduces the residual risk of transmission of HBV 
infection beyond that which can be achieved by screening donors using only HBsAg and 
total anti-HBc tests (Refs. 2, 8).  In addition, it can detect breakthrough infections in 
previously vaccinated individuals who are exposed to the virus, and HBV mutants appear 
to be more likely detected by HBV NAT than by HBsAg assays (Ref. 9).2   
 
HBV has been transmitted by tissue transplantation (Refs. 10 through 14).  Available 
literature has indicated possible transmissions of HBV by hematopoietic stem cells and 
blood with HBV NAT positive/hepatitis B surface antibody (anti-HBs) positive/HBsAg 
negative blood, irrespective of anti-HBc test results (Refs. 15 through 17).   
 
The estimated probability of HBV viremia at the time of tissue donation was determined 
to be 1 in 34,000; this is higher than the probability of viremia in first-time blood donors.  
HBV NATs potential utility in further reducing risk of HBV transmission by 
transplantation is mainly restricted to the early HBsAg-negative phase of infection.  It 
was estimated that the probability of donor viremia could be reduced to 1 in 100,000 if 
HBV NAT individual testing were used (Ref. 10).  Therefore, by analogy to the 
experience in the blood donor setting, it is reasonable to expect that the residual risk of 
transmission of HBV infection would be reduced by adding HBV NAT to the testing 
strategy for HCT/P donors. 
 
In the United States, there are currently FDA-licensed HBV NAT assays intended to 
screen blood samples from donors of whole blood and blood components, other living 
donors (individual organ donors when specimens are obtained while the donors heart is 
still beating), and blood specimens from cadaveric (non-heart-beating) donors.  Some of 
these are multiplex assays that can simultaneously detect HIV, HCV, and HBV in a 
single blood specimen, thus improving the feasibility of routine NAT testing for HBV.   
 
In summary, the available scientific data and the availability of FDA-licensed assays 
support a recommendation that all HCT/P donors should be tested using an FDA-licensed 
HBV NAT.   
                                                 
2 According to the Blood Products Advisory Committee (BPAC), there is no assumption of non-infectivity to 
recipients of blood products from donors with breakthrough infections (Ref. 18).  Similarly, there can be no 
assumption of non-infectivity of HCT/Ps from donors with breakthrough infections containing HBV DNA and 
vaccine-induced, HBV-neutralizing anti-HBs when transplanted into recipients.   
3  Contains Nonbinding Recommendations 
 
III.  RECOMMENDATIONS 
 
In order to adequately and appropriately reduce the risk of relevant communicable disease agent 
or disease transmission (21 CFR 1271.85(a)(3)), we recommend that you test HCT/P donors for 
HBsAg and for total anti-HBc (IgG and IgM) (Refs. 1, 10, and 19). 
 
In addition, FDA recommends that you test HCT/P donors for HBV using an FDA-licensed NAT 
donor screening test in accordance with the manufacturers instructions.  When interpreting the 
test results, consider the following recommendations:   
 
  Any HCT/P donor whose specimen tests negative (or non-reactive) in all three assays 
(i.e., HBsAg, total anti-HBc (IgG and IgM), and HBV NAT) may be considered to be 
negative (or non-reactive) for purposes of making a donor eligibility determination. 
 
  Any HCT/P donor whose specimen tests positive (or reactive) using any of the assays 
(i.e., HBsAg, total anti-HBc (IgG and IgM), or HBV NAT) is considered ineligible  
(21 CFR 1271.80(d)(1)).3 
 
 
IV.  IMPLEMENTATION 
 
We recommend that you implement the recommendations in this guidance within six months 
after the guidance issuance date.  These recommendations apply to all HCT/Ps recovered on or 
after implementation date. 
                                                 
3 Recommendations regarding donor screening for HBV can be found in sections IV.E. and F., and 
recommendations for donor testing for HBV, including interpretation of positive anti-HBs results, can be found in 
section VI.A. of the Guidance for Industry:  Eligibility Determination for Donors of Human Cells, Tissues, and 
Cellular and Tissue-Based Products (HCT/Ps) (Ref. 1).  
4  Contains Nonbinding Recommendations 
 
 
V.  REFERENCES  
 
1.  Guidance for Industry:  Eligibility Determination for Donors of Human Cells, Tissues, 
and Cellular and Tissue-Based Products (HCT/Ps), August 2007, 
http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulator
yInformation/Guidances/CellularandGeneTherapy/ucm078703.pdf. 
2.  Guidance for Industry:  Use of Nucleic Acid Tests on Pooled and Individual Samples 
from Donors of Whole Blood and Blood Components, including Source Plasma, to 
Reduce the Risk of Transmission of Hepatitis B Virus, October 2012, 
http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformatio
n/Guidances/Blood/ucm327850.htm. 
3.  World Health Organization.  Hepatitis B, July 2016, 
http://www.who.int/mediacentre/factsheets/fs204/en/.  
4.  Centers for Disease Control and Prevention.  Surveillance for Viral Hepatitis  United 
States, 2013, http://www.cdc.gov/hepatitis/statistics/2013surveillance/commentary.htm. 
5.  Alter, M.J., Centers for Disease Control and Prevention, Epidemiology of HBV and 
Programs on Prevention.  Presentation to the Advisory Committee on Blood Safety and 
Availability.  Transcript. August 27, 2004, https://wayback.archive-
it.org/3919/20140404142428/http://www.hhs.gov/ash/bloodsafety/advisorycommittee/pa
stmeetings/transcripts/acbsa08272004.pdf. 
6.  Ganem, D., Prince, A.M., Hepatitis B Virus InfectionNatural History and Clinical 
Consequences.  New England Journal of Medicine, 350; 1118-1129 (2004). 
7.  Kleinman, S.H., Lelie, N., et al., Infectivity of Human Immunodeficiency Virus-1, 
Hepatitis C Virus, and Hepatitis B Virus and Risk of Transmission by Transfusion. 
Transfusion, 49; 2454-2489 (2009). 
8.  Roth, W.K., Weber, M., et al., NAT for HBV and anti-HBc testing increase blood safety. 
Transfusion, 42; 869-875 (2002).  
9.  Abushady, E.A., Gameel, M.M., et al., HBV vaccine efficacy and detection and 
genotyping of vaccinee asymptomatic breakthrough HBV infection in Egypt.  World 
Journal of Hepatology, 3;147-156 (2011). 
10.  Zou, S., Dodd, R.Y., et al., Probability of Viremia with HBV, HCV, HIV, and HTLV 
among Tissue Donors in the United States.  New England Journal of Medicine, 351; 751-
759 (2004). 
11.  Morris, A., Strickett, M.G., et al., Use of Aortic Valve Allografts From Hepatitis B 
Surface Antigen-Positive Donors.  Annals of Thoracic Surgery, 49; 802-805(1990). 
12.  O'Day, D.M., Diseases Potentially Transmitted Through Corneal Transplantation. 
Ophthalmology, 96; 1133-1137, discussion 1137-1138 (1989). 
13.  Raber, I.M., Friedman, H.M., Hepatitis B Surface Antigen in Corneal Donors.  American 
Journal of Ophthalmology, 104; 255-258 (1987). 
5  Contains Nonbinding Recommendations 
 
14.  Thijssen, E.J., Kroes, A.C. et al., The significance of complete serological testing for 
hepatitis B in heart valve banking.  Transplantation, 56; 82-84 (1993). 
15.  Hui, C., Sun, J., et al., Occult Hepatitis B Virus Infection in Hematopoietic Stem Cell 
Donors in a Hepatitis B Virus Endemic Area.  Journal of Hepatology, 42; 813-819 
(2005). 
16.  Gerlich, W.H., Wagner, F.F., et al., HBsAg Non-Reactive HBV Infection in Blood 
Donors:  Transmission and Pathogenicity.  Journal of Medical Virology, 79 (Suppl.1); 
S32-S36 (2007). 
17.  Levicnik-Stezinar, S., Rahne-Potokar, U., et al., Anti-HBs positive occult hepatitis B 
virus carrier blood infectious in two transfusion recipients.  Journal of Hepatology, 48; 
1022-1025 (2008). 
18.  Biswas, Robin, Blood Donor Screening for Hepatitis B Virus (HBV) Infection by Nucleic 
Acid Testing (NAT).  Presentation to the Blood Products Advisory Committee 94th 
Meeting, Transcript April 1, 2009, 
http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/BloodVaccinesa
ndOtherBiologics/BloodProductsAdvisoryCommittee/ucm121612.htm. 
19.  Stramer, S.L., Wend, U., et al., Nucleic Acid Testing to Detect HBV Infection in Blood 
Donors.  New England Journal of Medicine, 364; 236-247 (2011). 
 
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