What are the next steps for a patient with Hepatitis B Surface Antibody (HBsAb) levels greater than 10 mIU/mL and a non-reactive Rapid Plasma Reagin (RPR) test?

Management of Patient with Hepatitis B Immunity and Non-reactive RPR

No further action is needed for a patient with Hepatitis B Surface Antibody (HBsAb) levels >10 mIU/mL and a non-reactive RPR test, as the patient has evidence of immunity to HBV and no evidence of syphilis infection. 1

Interpretation of Hepatitis B Serology

• The patient's HBsAb level of 2506.0 mIU/mL is significantly above the protective threshold of 10 mIU/mL, indicating strong immunity against hepatitis B virus infection 2, 1
• Anti-HBs ≥10 mIU/mL is considered the standard threshold for protective immunity against HBV infection according to CDC guidelines 1
• Immunocompetent persons with anti-HBs ≥10 mIU/mL have long-term protection and do not need further periodic testing to assess anti-HBs levels 2, 1
• The high antibody level (2506.0 mIU/mL) suggests robust immunity that is likely to be long-lasting, as demonstrated by studies showing protection for up to 30 years after vaccination 3

Interpretation of RPR Result

• The non-reactive RPR test indicates no evidence of syphilis infection 2
• No further testing or treatment for syphilis is needed at this time 2

Management Recommendations

For Hepatitis B:

• No additional hepatitis B vaccination is required as the patient has demonstrated strong immunity 2, 1
• No further serologic testing for hepatitis B is needed in immunocompetent individuals 2
• The patient should be informed that they are protected against future HBV infection 2

Special Considerations:

• If the patient is immunocompromised (e.g., HIV-infected, on immunosuppressive therapy, receiving hemodialysis), annual testing of anti-HBs may be warranted 2, 1
• For hemodialysis patients, a booster dose would be recommended if anti-HBs levels fall below 10 mIU/mL 2
• For transplant candidates or recipients, regular monitoring of anti-HBs levels (once per year) is recommended with a booster dose if antibody levels fall under 10 mIU/mL 2

Clinical Pearls and Pitfalls

• While anti-HBs ≥10 mIU/mL indicates protection against clinical disease, it may not provide sterilizing immunity; subclinical infection can still occur upon exposure to HBV 4
• The presence of anti-HBs appears to protect against clinical HBV reactivation, with higher titers (>30 IU/L) providing more robust protection 5
• The high anti-HBs level in this patient (2506.0 mIU/mL) suggests excellent protection against both clinical disease and viral reactivation 5
• No evidence suggests that patients with isolated anti-HBs positivity (without HBsAg or anti-HBc) need any further evaluation or monitoring if they are immunocompetent 2, 1

Documentation

• Document in the medical record that the patient has protective immunity against hepatitis B virus and a negative RPR test 1
• If the source of immunity is unknown (vaccination vs. natural infection), a complete serologic panel including anti-HBc could be considered to distinguish between immunity from vaccination versus resolved natural infection 1