T he implementation of nucleic acid testing (NAT) in blood donations from areas with high or low prevalence of hepatitis B virus (HBV) infection has resulted in the identification of a small number of infections in the preseroconversion window period (WP) 1 and a considerably larger number of blood units containing no detectable hepatitis B surface antigen (HBsAg) but low levels of HBV DNA associated, in most cases, with anti-HBc, suggesting an established infection. These cases were called occult HBV infection (OBI). 2 In Europe, where HBV genotypes A2 and D are prevalent, OBIs are detected in 1:2,000 to 1:20,000 donations 3,4 and are characterized by occurring in older donors (median age 51), mostly males (90%), and with normal levels of alanine aminotransferase (ALT). Viral load is consistently below 1,000 IU/mL (median, 25 IU/mL) and, compared to the dominance of genotype A2 in HBsAg-positive infections, a significantly higher proportion of OBI genotype D is observed. The remarkably high frequency of multiple amino acid substitutions in the pre-S/S proteins (100% in the major hydrophilic region [MHR] of genotype D OBIs) affecting both humoral and cellular epitopes strongly suggested that OBIs in Europe appears, to a large extent, determined by host immune pressure.