What are the recommendations for a healthcare worker with an anti-HBs (hepatitis B surface antibody) titre less than 10 mIU/mL and no history of hepatitis B vaccination?

Management of Healthcare Worker with Anti-HBs <10 mIU/mL and No Vaccination History

This healthcare worker should immediately begin a complete 3-dose hepatitis B vaccine series, with the first dose administered as soon as possible, followed by doses at 1 month and 6 months, and then undergo postvaccination serologic testing 1-2 months after completing the series. 1

Immediate Vaccination Requirements

Primary Vaccination Series

• All unvaccinated healthcare workers whose work involves reasonably anticipated risk for exposure to blood or infectious body fluids must receive the complete ≥3-dose hepatitis B vaccine series. 1
• The vaccination series should be completed before trainees have contact with blood, as higher risk has been documented during the professional training period. 1
• Administer the vaccine in the deltoid muscle according to the standard schedule: 0,1, and 6 months. 1

Critical Timing Consideration

• Because this worker has no history of vaccination, they are currently unprotected and susceptible to HBV infection and should be considered at immediate occupational risk. 1
• The first dose should be administered without delay, as persons with incomplete or no vaccination series are not considered protected. 1

Postvaccination Serologic Testing Protocol

Testing Requirements

• Mandatory postvaccination serologic testing must be performed for all healthcare workers at high risk for occupational percutaneous or mucosal exposure to blood or body fluids. 1
• Testing should be performed 1-2 months after administration of the final dose of the vaccine series using a quantitative method that allows detection of anti-HBs ≥10 mIU/mL (e.g., ELISA). 1

Interpretation of Results

If anti-HBs ≥10 mIU/mL:

• The healthcare worker is considered immune and protected. 1
• Document this result permanently in their occupational health record. 1
• No further periodic testing or booster doses are needed for immunocompetent persons. 1, 2

If anti-HBs <10 mIU/mL after primary series:

• Administer a second complete 3-dose vaccine series on an appropriate schedule. 1
• Repeat anti-HBs testing 1-2 months after the third dose of the second series. 1
• This approach (completing all 6 doses before retesting) is more practical than testing after each individual dose. 1

Management of Non-Responders (After 6 Total Doses)

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

Testing for infection status:

• Test for HBsAg and anti-HBc to determine if the person is infected. 1

If HBsAg-negative (not infected):

• The healthcare worker is a confirmed non-responder and should be considered susceptible to HBV infection. 1
• Counsel about precautions to prevent HBV infection. 1
• Document that they require HBIG (hepatitis B immune globulin) postexposure prophylaxis for any known or likely exposure to HBsAg-positive blood. 1
• No additional vaccination is necessary after 6 doses. 1

If HBsAg-positive (infected):

• Provide counseling on preventing HBV transmission to others. 1
• Refer for further evaluation (HBV viral load testing), care, treatment, and services. 1
• If performing exposure-prone procedures, seek counsel from an expert review panel regarding safe practice. 1
• They should not be excluded from work. 1

Postexposure Management While Unvaccinated

If Exposure Occurs Before Vaccination Series Completion

For HBsAg-positive source exposure:

• Administer 1 dose of HBIG immediately (preferably within 24 hours, effectiveness unclear after 7 days). 1, 3
• Administer hepatitis B vaccine in the deltoid muscle as soon as possible after exposure; HBIG should be given at a separate injection site. 1
• Complete the 3-dose vaccine series regardless of source HBsAg status. 1
• Perform postvaccination testing 4-6 months after HBIG administration (to allow HBIG antibodies to clear). 1

For unknown source exposure:

• Begin the hepatitis B vaccine series within 7 days of exposure. 3
• No HBIG is required if source status is unknown. 1

Common Pitfalls to Avoid

Critical Errors in Management

• Do not delay the first vaccine dose while waiting for additional testing or documentation—start immediately. 1
• Do not assume that a low anti-HBs titer from a previous unknown exposure provides protection; this worker needs full vaccination. 1
• Do not perform postvaccination testing too early (must wait 1-2 months after final dose) or the result will be unreliable. 1
• Do not give booster doses to non-responders after 6 total doses—additional vaccination beyond 6 doses is not recommended. 1

Documentation Requirements

• Document vaccination dates and lot numbers for all doses administered. 1
• Document postvaccination anti-HBs results permanently in the occupational health record. 1, 2
• For non-responders, clearly document their susceptibility status and need for HBIG after exposures. 1