Hepatitis B Vaccination: Indications, Antibody Titers, and Non-Responder Management
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1. Who Should Receive the Hepatitis B Vaccine
Universal vaccination is recommended by CDC, WHO, and Thai MOPH:
A. Infants
- Birth dose within 24 hours of delivery (prevents perinatal transmission)
- Complete 3-dose primary series at 0, 1, and 6 months.
B. Unvaccinated Children & Adolescents (<19 years old)
- Catch-up schedule: 3 doses at 0, 1, and 6 months.
C. Unvaccinated Adults (Any Age) Who Are at Risk
- Healthcare workers
- People with multiple sex partners or recent STI
- Men who have sex with men (MSM)
- Injection drug users
- Household/sexual contacts of HBsAg-positive individuals
- Chronic liver disease patients (HCV, NAFLD, cirrhosis)
- End-stage renal disease/dialysis patients
- Travelers to HBV-endemic areas
- Persons with HIV infection
D. Anyone Who Requests Vaccination
- Regardless of risk factors.
2. Anti-HBs Titer Interpretation & Action
| Anti-HBs (mIU/mL) | Meaning | Action |
|---|---|---|
| ≥10 mIU/mL | Protective immunity | If completed 3 doses → no further vaccine.If incomplete → give remaining doses. |
| <10 mIU/mL (never vaccinated/incomplete series) | Not immune | Start or complete 3-dose series (0, 1, 6 months). |
| <10 mIU/mL (after complete 3-dose series) | Primary non-responder | Repeat another full 3-dose series, retest 1–2 months after last dose. |
| <10 mIU/mL (after 6 doses) | Permanent non-responder | Test HBsAg & anti-HBc to rule out chronic HBV; give HBIG if exposed. |
| ≥100 mIU/mL | High responder | No booster in immunocompetent persons. |
| 10–99 mIU/mL | Low responder but still protected | No booster if completed series; if incomplete, finish doses. |
Key threshold: 10 mIU/mL = protective immunity.
3. Management of Non-Responders
Definition: Anti-HBs <10 mIU/mL 1–2 months after completing the 3-dose series.
Steps:
- Give a repeat full series (3 doses).
- Retest anti-HBs 1–2 months after last dose.
- If still <10 mIU/mL:
- Classify as permanent non-responder.
- Test for HBsAg and anti-HBc to check for chronic infection.
- Educate about risk avoidance.
- Provide HBIG if exposed to HBV.
4. Missed or Delayed Doses (“Missing Announcement” Scenario)
- Never restart the series, regardless of time elapsed.
- Just continue from where left off, respecting minimum intervals:
- Dose 1 → Dose 2: ≥4 weeks
- Dose 2 → Dose 3: ≥8 weeks
- Dose 1 → Dose 3: ≥16 weeks
5. Special Case: Two Doses Only, Protective Titer
- If anti-HBs ≥10 mIU/mL but series incomplete → give final dose now.
- Even if last dose was >1 year ago, do not restart.
- Third dose ensures long-term immunity.
6. Co-Administration with Influenza Vaccine
- Safe to give both on the same day.
- Use different arms, or if same arm, separate sites by ≥2.5 cm.
- Both are intramuscular (IM):
- HepB: Deltoid (adult) or anterolateral thigh (child)
- Influenza: Same sites as above.
- Document site for each vaccine.
7. Practical Summary Table
| Scenario | Anti-HBs Result | Action |
|---|---|---|
| Never vaccinated | N/A | Start full 3-dose series |
| Incomplete series | ≥10 | Complete series |
| Incomplete series | <10 | Complete series |
| Completed series | ≥10 | No action |
| Completed series | <10 | Repeat full series |
| After 6 total doses | <10 | Permanent non-responder protocol |
8. Clinical Bottom Line
- 10 mIU/mL = protective immunity.
- Always complete the 3-dose series, even if early titer is positive.
- Never restart — just continue.
- Non-responders get another full series; if still negative, classify as permanent non-responder.
- Can co-administer with influenza vaccine safely.
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