Challenges and Controversies

If documentation were available then it would not be a memory question. I would say it is unusual for children to remember exactly which vaccines they got, unless it was something like smallpox, which leaves a distinctive scar, or my childhood polio vaccines in the form of a pink sugar cube.

If in fact she got a complete hepatitis B series, she might now have some cellular immunity, but has no demonstrable antibody protection. The fact that some people do not respond so well to hepatitis B immunization is well described. To ensure that she is protected, along with household members and future sex partners, she should start a complete two or three shot series against this cancer-causing infection.

If a patient screens susceptible/non-immune to hepatitis B virus (HBV) but reports a prior history of HBV vaccination without documentation, I will offer either:
1) A repeat HBV vaccination with 2-dose Heplisav-B (preferred, if available)
-OR-
2) A booster dose followed by repeat anti-HBs testing in 1 to 2 months if only the 3-dose HBV vaccine is available.

There are 3 possible explanations for the patient’s HBV susceptible/non-immune result.
1. She completed the 3-dose vaccine she received as a child but has waning immunity from decades passed without HBV exposure and thus her anti-HBs titers have decreased over time. If she is re-challenged with a booster vaccine or through environmental exposure to HBV, she would mount an amnestic immune response (1).
2. She completed the 3-dose vaccine she received as a child but never mounted a sufficient immune response and thus is still susceptible to HBV infection. The response to HBV vaccine may depend on several host factors; an estimated 5-15% of persons do not mount a sufficient immunity to the traditional 3-dose hepatitis B vaccine.
3. She did not initiate or complete the HBV vaccine series as a child and is susceptible to HBV infection.

In the absence of documented HBV vaccine completion or prior post-vaccination serology testing demonstrating an immune response (such as is standard in infants born to HBsAg-positive mothers or health care workers), I adjust the strength of my recommendation for repeat vaccination depending on the patient's risk factors for future HBV exposure, including having close household or community contacts with hepatitis B, work in health care or as public safety worker, history of sexually transmitted infections, or being on hemodialysis or immunosuppressed.

For clinical settings that stock the 2-dose Heplisav-B vaccine for non-pregnant adults, I recommend administering the full 2-doses of the vaccine series since data on Heplisav-B suggests that is it more immunogenic and potentially more cost effective than the traditional 3-dose vaccine series, especially in patients with a history of inadequate immune response to the 3-dose HBV vaccine (2, 3). Also two intramuscular injections given 1 month apart may be easier to complete than 1 vaccine dose followed by a blood draw 1 to 2 months later with the possibility of needing the 2nd vaccine. If this option is opted for, I would still perform post-vaccination serologic testing (with anti-HBs 1 to 2 months after the vaccine is completed for certain high risk groups including (4):
• Persons with HBsAg-positive sexual or household contacts
• Health care or public safety workers
• Persons with end-stage renal disease on hemodialysis, or persons who are immunosuppressed.

If only the 3-dose series was available, then I would likely offer just one booster dose and then repeat anti-HBs 1 to 2 months later to evaluate for an immune response and if no response, then would advise completion of the whole vaccine.