What are the management options for a low or negative hepatitis B (HB) titer?

Management of Low or Negative Hepatitis B Titer

For individuals with low or negative hepatitis B surface antibody (anti-HBs) titers (<10 mIU/mL), a booster vaccination is recommended for high-risk groups including healthcare workers, dialysis patients, immunocompromised individuals, and those with occupational exposure risk, while routine boosters are not necessary for immunocompetent individuals with previous adequate vaccination. 1

Assessment of Hepatitis B Immunity

The management approach depends on the individual's risk category and immune status:

Immunocompetent Individuals

• Anti-HBs levels can decline or disappear over several decades after vaccination
• Despite antibody decline, most vaccinated immunocompetent individuals maintain immune memory
• No need for booster vaccination in immunocompetent subjects with low titers 1
• Regular anti-HBs titer testing or booster vaccination is not necessary for immunocompetent individuals 2

High-Risk Groups Requiring Monitoring and Potential Boosters

• Healthcare workers
• Sexual partners of HBV carriers
• HIV-infected individuals
• Dialysis patients
• Other immunocompromised patients
• Newborns of HBV-infected mothers

Management Algorithm

For Dialysis Patients and Immunocompromised Individuals:

1. Monitor anti-HBs levels annually
2. If anti-HBs level falls below 10 mIU/mL, administer a booster dose 1
3. Continue monitoring after booster to ensure adequate response

For Healthcare Workers:

1. Perform post-vaccination testing 1-2 months after completing initial vaccination series 3
2. For those with documented previous immunity but current low titers:
   • Consider booster vaccination, especially if high-risk exposure is anticipated
   • Evidence shows good anamnestic response in previously vaccinated individuals 3

For Post-Exposure Management:

If an individual with low/negative anti-HBs is exposed to HBV:

1. Administer HBIG (0.06 mL/kg) as soon as possible (preferably within 24 hours)
2. Administer hepatitis B vaccine concurrently
3. Complete post-exposure prophylaxis within 7 days for percutaneous exposure or 14 days for sexual exposure 1

Special Considerations

Immunocompromised Patients:

• Higher risk of vaccine non-response or waning immunity
• May require higher vaccine doses or reinforced vaccination schedule 1
• Regular serological testing recommended
• Booster vaccination to maintain anti-HBs ≥10 IU/mL is recommended 2

Renal Transplant Recipients:

• All HBsAg-positive renal transplant recipients should receive entecavir (ETV) or tenofovir alafenamide (TAF) as prophylaxis or treatment 1
• HBsAg-negative, anti-HBc positive renal transplant recipients require monitoring but not routine prophylaxis

Patients Undergoing Immunosuppressive Therapy:

• All candidates for chemotherapy and immunosuppressive therapy should be tested for HBV markers prior to immunosuppression 1
• HBsAg-positive patients should receive ETV, TDF, or TAF as treatment or prophylaxis
• Prophylaxis should continue for at least 12 months (18 months for rituximab-based regimens) after cessation of immunosuppressive treatment 1

Pitfalls and Caveats

1. Don't assume that low anti-HBs titer always indicates lack of protection in previously vaccinated individuals - cellular immune memory may provide protection despite antibody levels below 10 mIU/mL 2

2. Avoid unnecessary booster doses in immunocompetent individuals with documented previous adequate response to vaccination

3. Don't miss identifying high-risk individuals who genuinely need booster vaccination (dialysis patients, immunocompromised individuals)

4. Remember that genetic factors may influence vaccine response - some individuals may be non-responders due to genetic polymorphisms affecting immune response 4

5. Be aware that post-vaccination testing is not necessary after routine vaccination in immunocompetent adults but is recommended for high-risk groups 1