What is the recommended course of action for a patient with no immunity to hepatitis B (HBV)?

Management of Patients with No Immunity to Hepatitis B

If a patient's labs show no immunity to hepatitis B (anti-HBs <10 mIU/mL), they should receive a complete revaccination series with three doses of hepatitis B vaccine at 0,1, and 6 months, followed by anti-HBs testing 1-2 months after the final dose. 1

Initial Assessment and Revaccination Protocol

Confirm Lack of Immunity

• Anti-HBs levels <10 mIU/mL indicate inadequate protection against HBV infection 1
• Before proceeding with revaccination, test for HBsAg to rule out chronic HBV infection, particularly if the patient has risk factors for HBV exposure 2

Standard Revaccination Approach

• Administer a complete 3-dose vaccine series at 0,1, and 6 months 1
• Most non-responders (44-100%) will develop protective antibody levels after receiving this second complete vaccination series 1
• Do not restart the series if interrupted—simply continue with the next dose when able 2
• The minimum interval between doses must be respected: at least 4 weeks between doses 1 and 2, at least 8 weeks between doses 2 and 3, and at least 16 weeks between doses 1 and 3 2

Post-Revaccination Testing

• Test anti-HBs levels 1-2 months after the final vaccine dose to confirm adequate response (≥10 mIU/mL) 1
• This timing is critical to accurately assess vaccine-induced immunity 2

Management Based on Patient Category

Healthcare Workers with Prior Complete Vaccination

If the patient is a healthcare worker who previously completed a full vaccine series but now has anti-HBs <10 mIU/mL:

• Give one additional vaccine dose immediately, followed by anti-HBs testing 1-2 months later 2
• If anti-HBs remains <10 mIU/mL after this single dose, complete revaccination with two additional doses (total of 6 doses across both series) 2
• Retest 1-2 months after the final dose to document immune status for future occupational exposures 2

High-Risk Populations Requiring Monitoring

Certain groups need more intensive follow-up after revaccination 1:

• Healthcare workers: Post-vaccination testing is mandatory to document immune status for occupational safety 2
• Dialysis patients: Require annual anti-HBs testing and booster doses when levels fall below 10 mIU/mL 2
• Immunocompromised individuals (HIV-positive, transplant recipients, chemotherapy patients): Consider annual testing and booster doses with ongoing exposure risk 2
• Sexual partners of HBsAg-positive persons: Must be vaccinated and achieve protective immunity 1

If Still No Response After Second Complete Series

Non-Responders After Two Complete Series

• If anti-HBs remains <10 mIU/mL after completing two full 3-dose series (6 total doses), the patient is considered a vaccine non-responder 2
• These individuals require special management for any future HBV exposures 2

Post-Exposure Management for Non-Responders

If a non-responder has a known exposure to HBV:

• Administer 2 doses of hepatitis B immune globulin (HBIG) at 0.06 mL/kg 2
• Give the first dose as soon as possible after exposure (preferably within 24 hours) 3
• Give the second dose 1 month later 2
• Do not give additional vaccine doses to persons who have already completed two full series 2

Special Considerations and Pitfalls

Common Pitfalls to Avoid

• Do not assume immunity based on prior vaccination alone—many vaccinated individuals lose detectable antibodies over time, though they may retain immune memory 4
• Do not delay revaccination while waiting for additional testing or risk stratification 2
• Do not restart the vaccine series if doses are delayed—simply continue from where you left off 2

Exposure Risk During Revaccination Period

• If the patient has a known exposure to HBV (needlestick, sexual contact, etc.) while undergoing revaccination:
  • Give HBIG (0.06 mL/kg) immediately, preferably within 24 hours 3
  • Administer vaccine simultaneously at a separate anatomical site 2
  • Complete the full vaccine series on schedule 2

Household and Sexual Contacts

• All household contacts and sexual partners of HBsAg-positive persons should be tested and vaccinated if they lack immunity 1
• This prevents ongoing transmission and protects vulnerable individuals 1

Additional Preventive Measures

• Consider hepatitis A vaccination for patients at risk of HBV exposure, as HAV/HBV coinfection increases mortality risk substantially 1

Documentation and Follow-Up

• Maintain written documentation of all vaccine doses and serologic test results 2
• For healthcare workers, this documentation is essential for managing future occupational exposures 2
• Schedule the 1-2 month post-vaccination testing appointment at the time of the final vaccine dose to ensure compliance 1