What are the next steps for a 32-year-old with a non-reactive Hepatitis B (HB) antibody test?

Management of Non-Reactive Hepatitis B Antibody in a 32-Year-Old

Vaccinate this patient with a complete hepatitis B vaccine series (3 doses at 0,1, and 6 months), then test for anti-HBs 1-2 months after the final dose to confirm protective immunity (≥10 mIU/mL). 1

Immediate Action: Initiate Vaccination

• All adults aged 19-59 years should receive hepatitis B vaccination, regardless of risk factors, eliminating the need for risk-based screening 1
• A non-reactive (negative) anti-HBs result indicates the patient lacks protective immunity and requires vaccination 2
• Multiple vaccine options are available with different schedules 1:
  • Heplisav-B: 2 doses at 0 and 1 month (fastest completion) 1
  • Recombivax HB or Engerix-B: 3 doses at 0,1, and 6 months 1
  • PreHevbrio: 3 doses at 0,1, and 6 months 1

Post-Vaccination Testing Protocol

• Test anti-HBs levels 1-2 months after completing the vaccine series using a method that detects the protective threshold of ≥10 mIU/mL 1, 2
• This post-vaccination testing documents the patient's immune response status for future reference 1

If Anti-HBs ≥10 mIU/mL After Primary Series:

• The patient is considered immune with long-term protection 2
• No further periodic testing or booster doses are needed in immunocompetent individuals 2
• Immunologic memory persists even when antibody levels decline below 10 mIU/mL over time 3, 4

If Anti-HBs <10 mIU/mL After Primary Series:

• Administer a complete second vaccine series (3 additional doses) 1, 2
• Retest anti-HBs 1-2 months after the final dose of the second series 1, 2
• Administering a full second series is more practical than testing after each individual dose 1

If Anti-HBs <10 mIU/mL After Two Complete Series:

• Test for HBsAg to rule out chronic hepatitis B infection 2
• These individuals are considered non-responders (approximately 5% of healthy adults) 5
• If HBsAg-negative, the patient should be counseled about lack of vaccine-induced protection 1

Important Clinical Considerations

Prevaccination Testing (Generally Not Required)

• Prevaccination serologic testing is not necessary for routine vaccination and should not delay vaccine administration 1
• Testing for HBsAg, anti-HBs, and anti-HBc may be considered in high-risk groups (persons born in endemic regions, HIV-positive persons, household contacts of HBsAg-positive persons) 2
• However, lack of access to testing should never be a barrier to vaccination 1

Special Populations Requiring Different Management

• Immunocompromised patients require annual anti-HBs testing and revaccination when levels fall below 10 mIU/mL 2
• Hemodialysis patients need higher vaccine doses (40 μg) and annual monitoring with booster doses if anti-HBs <10 mIU/mL 1, 2
• Pregnant women should receive Engerix-B, Recombivax HB, or Twinrix (not Heplisav-B or PreHevbrio due to insufficient safety data) 1

Common Pitfalls to Avoid

• Do not test for anti-HBs in unvaccinated or incompletely vaccinated persons, as the ≥10 mIU/mL correlate of protection has only been validated for those completing an approved vaccination series 1, 2
• Do not delay vaccination while awaiting test results in susceptible individuals 1
• Do not assume immunity based on age alone—many adults in this age group were not vaccinated as infants (universal infant vaccination began in 1991) 5