What serologic tests are recommended for pre-employment hepatitis B screening in individuals with unknown vaccination status or previous test results?

Pre-Employment Hepatitis B Screening Tests

For healthcare personnel with unknown vaccination or immunity status, measure anti-HBs (antibody to hepatitis B surface antigen) upon hire, and if levels are <10 mIU/mL, administer additional vaccine doses with retesting. 1

Testing Approach Based on Employment Context

For Healthcare Personnel (HCP) with Documented Complete Vaccination

• Measure anti-HBs only upon hire or matriculation if the employee has documentation of a complete hepatitis B vaccine series (≥3 doses) 1
• Use a quantitative assay (such as ELISA) that allows detection of the protective concentration of anti-HBs ≥10 mIU/mL 1, 2
• If anti-HBs is ≥10 mIU/mL: No further action needed for hepatitis B prophylaxis 1, 2
• If anti-HBs is <10 mIU/mL: Administer one dose of hepatitis B vaccine and retest 1-2 months later 1, 3

For Healthcare Personnel with Unknown or Incomplete Vaccination Status

Order the complete three-marker panel: HBsAg, anti-HBs, and anti-HBc to determine both infection status and immunity 1

This comprehensive testing approach serves multiple purposes:

• HBsAg identifies current chronic or acute hepatitis B infection 1, 4
• Anti-HBs identifies immunity from either vaccination or past infection 1, 4
• Anti-HBc distinguishes natural immunity (past infection) from vaccine-induced immunity 1, 5

Rationale for the Three-Marker Panel

The CDC specifically recommends testing for HBV infection (HBsAg, anti-HBs, and anti-HBc) for persons born in countries of high and intermediate HBV endemicity (≥2% prevalence), which may include many pre-employment candidates 1

Testing for anti-HBc is particularly valuable in occupational settings because it identifies individuals with past HBV exposure who have cleared the infection, and it proves to be a better indicator of intense exposure to blood and hepatitis B than anti-HBs alone 5

Common Pitfalls to Avoid

Do not use anti-HBc as the only screening test for HBV immunity, as it cannot distinguish between immunity and chronic infection 4

Do not delay vaccination while waiting for test results in high-risk settings—the first dose of hepatitis B vaccine should typically be administered immediately after collection of blood for serologic testing 1

Be aware that anti-HBs levels wane over time after childhood vaccination, so testing HCP years after vaccination might not distinguish vaccine nonresponders from responders whose antibody levels have declined 1

Alternative Institutional Approaches

Some healthcare institutions may choose not to measure anti-HBs upon hire for HCP with documented complete vaccination series, instead ensuring timely assessment and postexposure prophylaxis following any exposure 1

This approach is acceptable in settings with:

• Documented low risk for occupational blood and body fluid exposures 1
• Lower prevalence of HBV infection in the patient population 1
• Reliable systems for HCP to recognize and report exposures 1

However, pre-hire testing is generally preferred because it ensures HCP will be protected before any potential exposure occurs, rather than relying on post-exposure management 1

Management of Non-Responders

If anti-HBs remains <10 mIU/mL after one booster dose: Administer two more doses of hepatitis B vaccine to complete a second series (6 doses total), then retest 1-2 months after the final dose 1, 3

If still non-responsive after 6 total doses: Test for HBsAg and anti-HBc to rule out chronic HBV infection, and counsel about the critical importance of immediate postexposure prophylaxis with HBIG plus vaccine if exposed to HBsAg-positive blood 3