Hepatitis B Exposure in a Vaccinated Nurse
An ICU nurse sustains a hollow-bore needlestick while recapping a needle after drawing blood from a patient with known chronic hepatitis B. The source patient is HBsAg positive, HBeAg negative, and HBV DNA 500 IU/mL. The nurse was vaccinated as a child and has a documented anti-HBs of 8 mIU/mL from a titer drawn 5 years ago; she has never received a booster. Her baseline HBsAg and anti-HBc are negative. She is 28 years old and pregnant at 10 weeks. The hospital’s exposure protocol requires source HIV and HCV testing, but the source patient’s HIV status is unknown and he refuses testing. The nurse is anxious and asks whether she should take hepatitis B immune globulin, whether the pregnancy affects treatment, and whether she can continue working. Employee health sees her 4 hours after exposure.
1. What post-exposure prophylaxis should be offered for hepatitis B, and does pregnancy change the recommendation?
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The nurse is not protected: anti-HBs 8 mIU/mL is below 10, and she has no booster history. Because the source is HBsAg positive, give hepatitis B immune globulin (HBIG) as soon as possible, ideally within 24 hours and up to 7 days after exposure. She should also receive a booster dose of HBV vaccine or restart a three-dose series per protocol; for a previously vaccinated person with inadequate response, revaccination is recommended. Pregnancy is not a contraindication to HBIG or recombinant HBV vaccine. Do not delay treatment while awaiting source HIV testing. Draw baseline HIV and HCV tests and offer HIV PEP if the source has risk factors or is HIV positive. Document the exposure and counsel the nurse.
2. What follow-up testing and work restrictions are appropriate?
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Follow anti-HBs 1–2 months after the final vaccine dose to document seroconversion. Test HBsAg and ALT if she develops symptoms or at baseline and follow-up per policy. She does not need work restriction now because she is not infected and has no acute hepatitis. If she becomes HBsAg positive, restrict her from exposure-prone procedures until she is evaluated; chronic HBV with high viral load may require additional restrictions. Pregnancy does not require restriction. Report the exposure per OSHA and facility policy, and ensure confidential follow-up. The key is completing the vaccine series and confirming immunity, not just giving HBIG.
3. The source patient refuses HIV testing. How should this be handled?
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Do not let the refusal delay HBV PEP. Assess the source’s HIV risk history and the exposure severity; if risk is substantial, offer HIV PEP according to guidelines, often within 72 hours. Many jurisdictions allow source testing in occupational exposures without consent, or require counseling and documentation; consult the facility’s policy and legal counsel. Tell the nurse the source refused and explain the uncertainty. Offer baseline and follow-up HIV testing. If the source later tests HIV positive, adjust PEP. Respect confidentiality but prioritize the nurse’s access to timely prophylaxis.