Hepatitis B Vaccination for a 45-Year-Old Without Evidence of Immunity in Ontario
Yes, this patient should absolutely receive the hepatitis B vaccine series—the Advisory Committee on Immunization Practices (ACIP) now recommends universal hepatitis B vaccination for all adults aged 19-59 years, regardless of risk factors. 1, 2
Universal Vaccination Guideline
The 2022 ACIP recommendation represents a major paradigm shift from previous risk-based approaches that resulted in suboptimal adult vaccination coverage. 1, 2 All adults aged 19-59 years should receive hepatitis B vaccination, and providers should offer vaccination without requiring patients to acknowledge specific risk factors. 2
This universal approach eliminates the need to identify or document individual risk factors, which historically created barriers to vaccination. 1
Vaccination Protocol for This Patient
Administer a standard 3-dose hepatitis B vaccine series using either Engerix-B (20 μg) or Recombivax HB (10 μg) at 0,1, and 6 months. 2
Alternative vaccine options include:
- Heplisav-B: 2-dose series (0 and 1 month) for adults ≥18 years 2
- PreHevbrio: 3-dose series for adults ≥18 years 2
Critical timing requirements: Maintain minimum intervals of 4 weeks between doses 1 and 2,8 weeks between doses 2 and 3, and 16 weeks between doses 1 and 3. 2
Pre-Vaccination Testing Not Required
Do not delay vaccination while awaiting serologic testing results. 2, 3 Pre-vaccination testing is not required and should not be a barrier to vaccination, especially in populations that are difficult to reach. 2
If you want to confirm the patient truly lacks immunity (rather than having waned antibody levels from prior vaccination or infection), you could order hepatitis B surface antibody (anti-HBs), hepatitis B surface antigen (HBsAg), and hepatitis B core antibody (anti-HBc) testing—but administer the first vaccine dose concomitantly with blood draw. 3
Post-Vaccination Testing
Routine post-vaccination serologic testing is NOT recommended for this patient. 2 Post-vaccination anti-HBs testing 1-2 months after series completion is only indicated for specific high-risk groups: healthcare personnel with occupational blood exposure risk, HIV-infected persons, hemodialysis patients, and other immunocompromised individuals. 2
Since this patient does not fall into these categories, simply complete the vaccine series without post-vaccination testing.
If the Series Is Interrupted
Never restart an interrupted vaccine series—simply continue where you left off, regardless of the time elapsed between doses. 2, 4 This is a common pitfall that wastes doses and delays protection. 2
Special Considerations if Testing Reveals Prior Exposure
If serologic testing shows isolated anti-HBc positivity (indicating past exposure) with negative anti-HBs, still proceed with the complete vaccine series. 3 The American College of Physicians recommends that patients with isolated anti-HBc should receive hepatitis B vaccination regardless of anti-HBs status. 3
Implementation in Ontario Primary Care
In primary care settings, providers should proactively offer hepatitis B vaccination to all adults aged 19-59 years without requiring patients to request it. 2 This shifts the responsibility of initiating vaccination consideration from the patient to the provider. 1
Consider implementing standing orders to vaccinate all adults in this age group who have not completed the series. 2