Educational Policy, Hepatitis Immunization, Nursing Education, Occupational Health, Secondary Immunization



  1. Elting, Julie Kientz


Abstract: Because of the risk of occupational exposure, preparation for nursing student clinical placement includes documentation of the hepatitis B immunization series. Requiring a hepatitis B antibody titer is less common. Immunity from the hepatitis B vaccine decreases over time, particularly for those immunized as infants. A record review of one nursing program that required both immunization and an antibody titer found 86 percent of students immunized as infants had low antibody levels, requiring reimmunization following 2013 Centers for Disease Control and Prevention guidelines. Nursing education programs that do not require antibody titers should reevaluate their policies to protect their students.


Article Content

For matriculation in health care educational programs, students must present immunization and screening records that meet occupational health requirements of clinical partners. These policies should be consistent with state and national public health recommendations and mandates to prevent the spread of communicable diseases (Centers for Disease Control and Prevention [CDC], 2015; Schillie et al., 2013). Documented immunity to hepatitis B virus (HBV) is especially important because of the risk of exposure in clinical rotations, particularly in areas with a high percentage of patients with chronic HBV infection. To document immunity, students submit the three-shot HBV immunization record at matriculation. Many educational programs also require a positive HBV surface antibody (anti-HBs) titer.


At one nursing educational program in Hawaii where titers were required, high numbers of negative anti-HBs titer results were noticed during clinical preparation, requiring follow-up with students using the CDC guidelines for health care workers (Schillie et al., 2013). With institutional review board approval, a complete records review was later conducted for 2016-2019 graduating cohorts of the nursing program.



The public health effort to control the spread of HBV infection through immunization spans the last 50 years. The introduction of a successful infant vaccination series in the 1980s was documented in countries and populations with endemic infection, including Gambia, American Samoa (Mendy et al., 2013; Spradling et al., 2013), and Alaskan natives (Dentinger et al., 2005). Based on recommendations from international and national public health organizations, many countries began endorsing policies in the 1990s for routine immunization of infants and catch-up vaccination for children to create an immune adult population (Schillie et al., 2018). In the United States, the recommendation by the Advisory Committee on Immunization Practices (ACIP) in 1993 was followed in ensuing years by state legislatures passing laws mandating HBV vaccination prior to school entry (Schillie et al., 2018). In 2016, the success of this US public health effort was demonstrated with data revealing the percentage of fully immunized teens ages 13 to 17 years was 91.4 percent (CDC, 2017).


It is documented that persistence of HBV surface antibody (anti-HBs) created by the vaccine decreases over time (Dentinger et al., 2005; Mendy et al., 2013; Middleman et al., 2014; Schillie et al., 2018; Spradling et al., 2013). Based on this literature, the CDC acknowledges that only 16 percent of young adults who were immunized as infants have anti-HBs of >10 mIU/ml, the recognized threshold for protection from HBV infection if measured following the three-shot series (CDC, 2018; Schillie et al., 2013, 2018). Questions regarding a need for a vaccination booster for these individuals immunized as infants have been addressed by the CDC, and the answer is "no" for the general population (Schillie et al., 2013).


The rationale against revaccination comes from two arms of HBV research. Follow-up HBV vaccination studies in endemic populations immunized in the 1980s reveal both a decrease in acute infections and, if infected, a dramatic decrease in chronic disease (Dentinger et al., 2005; Mendy et al., 2013; Schillie et al., 2018; Spradling et al., 2013). Other studies in nonendemic populations, including the United States, reveal robust response to boosters given to teens or young adults immunized against HBV as infants. This theoretically demonstrates a strong amnesic response if exposed to HBV, which prevents chronic disease (Middleman et al., 2014; Schillie et al., 2018). Because the burden of HBV, for individuals and society, is linked to chronic disease, the CDC endorses this as a sound public health policy (Schillie et al., 2018).


Separate recommendations were made by ACIP and CDC in 2013 for health care students and employees with potential for blood and body fluid exposure in the workplace. It is recommended that HBV immunization status of students be presented, along with serological documentation of immunity at matriculation (Schillie et al., 2013). If this preexposure testing does not detect anti-HBs of >10 mIU/ml, the student may be given one HBV vaccine booster and have another titer drawn six to eight weeks later. If the response to the booster is inadequate, the vaccination series should be completed, and the individual retitered. Only 5 percent remain negative at this point and should receive education about appropriate management of their nonconversion during their educations and careers (CDC, 2015).



This was a nonexperimental, descriptive study. After institutional review board approval, deidentified secondary data from the immunization and screening records of 241 undergraduate nursing students from the 2016-2019 graduating cohorts were obtained. Dates of birth, dates of the three-shot HBV immunization series, and the results of the surface antibody (anti-HBs) serological testing performed at matriculation were reviewed. General demographic information of the undergraduate students was obtained through a separate nursing program database.



There were 241 BSN students in the 2016-2019 cohorts; 92 met inclusion criteria with documentation of the three-shot HBV immunization series received under one year of age. Of the 92 in the sample, 85.9 percent (79/92) had a negative HBV surface antibody titer (anti-HBs < 10 mIU/ml) at matriculation. Specific demographics from the sample were not available as data were deidentified when retrieved from the immunization and screening records per institutional review board directive. The reported general demographic information from the nursing program in 2017-2018 was 85% women and 15% men; 45% Asian, 26% Native Hawaiian/Pacific Islander, and 11% Caucasian.



The results from this study are significant for multiple reasons. First, they are consistent with HBV antibody persistence data cited by the CDC in their recommendations for evaluating HBV protection in health care workers immunized as infants (Schillie et al., 2013). Although the literature indicates protection against chronic disease persists even with lower levels of anti-HBs, from an occupational health perspective, the results document the exposure risk in this population; prevention of infection in health care workers and students is paramount, and CDC recommendations should be followed. The data also contribute to the body of evidence that guides CDC public health policy regarding serological testing of health care students and workers immunized as infants.



Preparing students for clinical placement is time-consuming for nursing programs, and the processing of student immunization and screening records is an ongoing challenge (Elting, 2018). The students whose information was later used for this study were first identified through the regular clinical preparation process. Although the students submitted a record of their three-shot HBV series, the negative surface antibody (anti-HBs) titer resulted in clinical clearance delays and renegotiation of placements with clinical partners. The knowledge that approximately 85 percent of students immunized against HBV as infants have negative titers can guide nursing program policies for early submission of clinical clearance documentation. With proper counseling, this would allow students time to address deficiencies and prevent clinical education delays.



Occupational immunization and screening requirements of health care personnel are based on CDC and ACIP recommendations. Beyond documentation of the three-shot HBV series, serological testing for HBV immunity should be completed at matriculation to any health care educational program or upon hire into health care organizations if not completed previously (Schillie et al., 2013). Although this process is in place at many institutions, anecdotal evidence suggests it is not universally followed. As more millennials enter the workforce, health care education programs and health care organizations should ensure policies are in effect that protect students and employees if exposed to HBV in the occupational setting.




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