ID Q&A - Hepatitis B Vaccination: What Next When the Patient Doesn’t Respond?

Q: An 8-year-old girl—whose mother is a hepatitis B carrier—received hepatitis B hyperimmune globulin and a hepatitis B vaccine at birth. This was followed by another 2 doses of hepatitis B vaccine. At 2 years of age, the child’s hepatitis B surface antigen was undetectable and her hepatitis B surface antibody was nonreactive. She was given another 3 doses of hepatitis B vaccine. Unfortunately, she was lost to follow-up until she recently returned to our practice. Both hepatitis B surface antigen and surface antibody were again measured and both were nonreactive.  Should this patient receive another series of high-dose hepatitis B vaccine? —Chih C. Chang, MD Tampa, Fla A: Your management of this child was absolutely correct and follows the recommendations of the Red Book Committee1 and those of the Infectious Diseases Society of America.2 The patient is either a nonresponder to the vaccine—as 3% of people are—or she generates other immune responses that we do not measure, such as cellular immune reactivity. There is good evidence that such persons are well protected from disease. There is one technical aspect that I should mention for completeness. Be sure the patient receives the vaccine by intramuscular injection in the anterolateral thigh or deltoid area rather than by subcutaneous injection. Administration in the buttocks or intradermally has been associated with decreased immunogenicity. Recommendations do not address the exact question of what to do for someone who has failed to respond to 2 series of hepatitis B vaccine. Therefore, there is no official guideline. I can tell you what my personal approach has been: I give a single booster dose of vaccine and do not obtain follow-up serology. I believe I have done everything I can at this point and explain to the patient and/or parents that he or she may not be protected and that high-risk behavior should be avoided. REFERENCES: 1. Hepatitis B. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2003:318-336. 2. Centers for Disease Control and Prevention. Vaccine preventable STDs. Sexually transmitted diseases treatment guidelines. MMWR. 2002;51(RR-6):59-64.