An 18-year-old patient, who has been in your practice since birth, is preparing for nursing school. Her school requires hepatitis B serology testing, and despite your records showing she received the primary hepatitis B series, her anti-HBs comes back “negative” (i.e., a measure of less than 10 mIU/mL). Frustrated, she schedules another series, wondering why her childhood vaccines “didn’t work.” Her mother comments, “This is why we shouldn’t vaccinate babies when they don’t need it!” — unintentionally planting seeds of vaccine hesitancy in a future healthcare provider.
Many healthcare providers have experienced a version of this scenario. While the necessary next clinical steps may be routine in our workflow, the need for testing and repeat vaccination can be frustrating and time consuming for patients. Intentionally navigating the communication around this process can not only remove frustration over the immediate situation, but it can also provide a broader context that fortifies vaccine confidence over the long term — something important for all but particularly for a future healthcare provider.
Communicating the reason for testing
As providers, we take the science behind testing antibody titers for granted. However, the process may seem opaque, even confusing, to families. Providing context and answering the “whys” may add a few minutes to the visit, but over time these types of conversations can provide foundational context and help you grow mutual trust and respect. Even if you do not see the same patients year after year, some healthcare provider somewhere is seeing them, and maintaining trust in the profession helps all of us.
For this family, background on the disease and the vaccine may be needed for context. Because the hepatitis B vaccine has been recommended for all infants and young children since 1991 and the vaccine produces long-term immunity, most young adults are protected against this virus. As this patient is going into healthcare, her risk of being exposed to hepatitis B virus is higher, and we want to be certain that she is protected from a virus that can cause liver disease or liver cancer.
Many patients will need some education to learn that lab testing to measure hepatitis B antibodies in the blood is a quick and easy way to evaluate if someone is protected, but it does not provide a full picture of someone’s immunity to the virus. The good news is that when antibodies comes back positive, we can be certain of a patient’s protection. But, circulating antibodies decrease over time and, therefore, may not be measurable. Even with a negative test, patients are most often still protected long term through T cells and cellular immunity.
For discussion purposes, let’s say our patient has tested negative, which happens in up to half of adults vaccinated as young children, meaning we will have to take some extra steps to be certain she has immunity. By mentioning this possibility upfront, the patient and her mom will be able to anticipate possible next steps and why they will be important.
Communicating the need for revaccination
With this patient’s undetectable titers, you can discuss the significance of testing for circulating antibodies and the challenges with measuring cellular immunity to serve as reasoning for next steps. Since your practice carries Heplisav-B, you recommend the two-dose series followed by repeat titers.
In this scenario, they can get a complete second series followed by a blood test one to two months later. Some providers opt to give one dose of vaccine followed by another blood test one to two months later. Two possible outcomes exist:
- If a patient has pre-existing immunity, they will begin to produce antibodies, causing the second blood test to show sufficient levels of antibody.
- If only one dose was administered and the test remains negative, the series should be completed with titers checked at the end of the series.
- If the test remains negative after a complete series, this suggests that the patient may be part of the 5%-10% of the population who don’t respond to hepatitis B vaccine (often called non-responders). In rare cases, a negative anti-HBs result indicates recovery from a past infection, which can be evaluated through getting complete serologies, or an immune deficiency, which can be considered in the context of the patient’s complete medical history.
When recommending a repeat vaccination series to patients, there may be a degree of hesitancy because of the time-consuming nature of additional appointments and decreased confidence in the vaccine, particularly if antibody testing has not been fully explained. Understanding our patients’ concerns can help tailor guidance to their case:
- Some patients may respond best to risk-based messaging, such as learning the occupational risk of exposure, as nearly 400,000 hospital-based healthcare workers in the U.S. experience needlestick injuries annually.
- Recognizing that health behaviors are influenced by social norms, others may find it more helpful to have this testing and revaccination process normalized, meaning they understand that many healthcare providers have had a similar experience.
- Others may want to understand the science behind the test results. Describing that the repeat series of vaccine will serve as a booster and restimulate antibody production may reduce concerns. Additionally, with a formulation like Heplisav-B, discussing the adjuvant in this vaccine may be of interest. This adjuvant, abbreviated CpG, contains C (cytosine) and G (guanine), which are building blocks of DNA, linked together to enhance the immune response. Discussing that the adjuvant allows for this vaccine to be given as only two doses instead of three may also be appealing since this option will be faster to complete and require fewer visits.
Communicating durability of protection
Two months after repeating a vaccine series, our patient is retested. As occurs with many individuals, her antibody titers are now positive, measuring 22,000 mIU/mL, ensuring that she is protected against hepatitis B as she enters her training.
If this patient continued to have undetectable titers, it would be important to share the significance of this result with her as a future healthcare provider so that if she is ever exposure to blood infected with hepatitis B, she is aware that she will need prompt clinical care to reduce risk of infection. Likewise, it will be important to ensure that she has the appropriate documentation and is aware to keep it where she can access it when she starts or changes jobs.
While communicating these nuanced issues can be time consuming, it is important that we take the time to do so — not only to ensure a positive current interaction but also to provide context and trust in the healthcare field.
Contributed by: Lori Handy, MD, MSCE , Charlotte A. Moser, MS, Paul A. Offit, MD
An 18-year-old patient, who has been in your practice since birth, is preparing for nursing school. Her school requires hepatitis B serology testing, and despite your records showing she received the primary hepatitis B series, her anti-HBs comes back “negative” (i.e., a measure of less than 10 mIU/mL). Frustrated, she schedules another series, wondering why her childhood vaccines “didn’t work.” Her mother comments, “This is why we shouldn’t vaccinate babies when they don’t need it!” — unintentionally planting seeds of vaccine hesitancy in a future healthcare provider.
Many healthcare providers have experienced a version of this scenario. While the necessary next clinical steps may be routine in our workflow, the need for testing and repeat vaccination can be frustrating and time consuming for patients. Intentionally navigating the communication around this process can not only remove frustration over the immediate situation, but it can also provide a broader context that fortifies vaccine confidence over the long term — something important for all but particularly for a future healthcare provider.
Communicating the reason for testing
As providers, we take the science behind testing antibody titers for granted. However, the process may seem opaque, even confusing, to families. Providing context and answering the “whys” may add a few minutes to the visit, but over time these types of conversations can provide foundational context and help you grow mutual trust and respect. Even if you do not see the same patients year after year, some healthcare provider somewhere is seeing them, and maintaining trust in the profession helps all of us.
For this family, background on the disease and the vaccine may be needed for context. Because the hepatitis B vaccine has been recommended for all infants and young children since 1991 and the vaccine produces long-term immunity, most young adults are protected against this virus. As this patient is going into healthcare, her risk of being exposed to hepatitis B virus is higher, and we want to be certain that she is protected from a virus that can cause liver disease or liver cancer.
Many patients will need some education to learn that lab testing to measure hepatitis B antibodies in the blood is a quick and easy way to evaluate if someone is protected, but it does not provide a full picture of someone’s immunity to the virus. The good news is that when antibodies comes back positive, we can be certain of a patient’s protection. But, circulating antibodies decrease over time and, therefore, may not be measurable. Even with a negative test, patients are most often still protected long term through T cells and cellular immunity.
For discussion purposes, let’s say our patient has tested negative, which happens in up to half of adults vaccinated as young children, meaning we will have to take some extra steps to be certain she has immunity. By mentioning this possibility upfront, the patient and her mom will be able to anticipate possible next steps and why they will be important.
Communicating the need for revaccination
With this patient’s undetectable titers, you can discuss the significance of testing for circulating antibodies and the challenges with measuring cellular immunity to serve as reasoning for next steps. Since your practice carries Heplisav-B, you recommend the two-dose series followed by repeat titers.
In this scenario, they can get a complete second series followed by a blood test one to two months later. Some providers opt to give one dose of vaccine followed by another blood test one to two months later. Two possible outcomes exist:
- If a patient has pre-existing immunity, they will begin to produce antibodies, causing the second blood test to show sufficient levels of antibody.
- If only one dose was administered and the test remains negative, the series should be completed with titers checked at the end of the series.
- If the test remains negative after a complete series, this suggests that the patient may be part of the 5%-10% of the population who don’t respond to hepatitis B vaccine (often called non-responders). In rare cases, a negative anti-HBs result indicates recovery from a past infection, which can be evaluated through getting complete serologies, or an immune deficiency, which can be considered in the context of the patient’s complete medical history.
When recommending a repeat vaccination series to patients, there may be a degree of hesitancy because of the time-consuming nature of additional appointments and decreased confidence in the vaccine, particularly if antibody testing has not been fully explained. Understanding our patients’ concerns can help tailor guidance to their case:
- Some patients may respond best to risk-based messaging, such as learning the occupational risk of exposure, as nearly 400,000 hospital-based healthcare workers in the U.S. experience needlestick injuries annually.
- Recognizing that health behaviors are influenced by social norms, others may find it more helpful to have this testing and revaccination process normalized, meaning they understand that many healthcare providers have had a similar experience.
- Others may want to understand the science behind the test results. Describing that the repeat series of vaccine will serve as a booster and restimulate antibody production may reduce concerns. Additionally, with a formulation like Heplisav-B, discussing the adjuvant in this vaccine may be of interest. This adjuvant, abbreviated CpG, contains C (cytosine) and G (guanine), which are building blocks of DNA, linked together to enhance the immune response. Discussing that the adjuvant allows for this vaccine to be given as only two doses instead of three may also be appealing since this option will be faster to complete and require fewer visits.
Communicating durability of protection
Two months after repeating a vaccine series, our patient is retested. As occurs with many individuals, her antibody titers are now positive, measuring 22,000 mIU/mL, ensuring that she is protected against hepatitis B as she enters her training.
If this patient continued to have undetectable titers, it would be important to share the significance of this result with her as a future healthcare provider so that if she is ever exposure to blood infected with hepatitis B, she is aware that she will need prompt clinical care to reduce risk of infection. Likewise, it will be important to ensure that she has the appropriate documentation and is aware to keep it where she can access it when she starts or changes jobs.
While communicating these nuanced issues can be time consuming, it is important that we take the time to do so — not only to ensure a positive current interaction but also to provide context and trust in the healthcare field.
Contributed by: Lori Handy, MD, MSCE , Charlotte A. Moser, MS, Paul A. Offit, MD