The first and primary strategy to decrease the risk of occupational infections by bloodborne pathogens is to prevent exposure by educating the HCWs on infection control and by vaccinating them. Therefore, a high level of knowledge, a positive attitude and strong HBV infection prevention practice are necessary for developing a practical HBV infection prevention approach [34].

Implementing HBV infection prevention practices like hepatitis B screening, hepatitis B vaccination, post-hepatitis B vaccination antibody testing, changing gloves for each client, not recapping needles after use, preventing needlestick injuries, and avoiding blood splashes on the body are examples of good practices [35]. HCWs need to be taught how to take appropriate precautions to prevent occupational exposure to blood and blood products, including avoiding unnecessary injections, using all necessary safety measures, HCWs should dispose sharp objects immediately after use. Recapping needles should be avoided, and using safer tools like needles that sheath or retract [36]. These preventive behaviors reflect both individual and institutional responsibilities. Sustained training, proper resource allocation, and regulatory enforcement are key to reducing occupational HBV exposure risks among HCWs.

Self-reported hepatitis B vaccination coverage among adults at risk for HBV infection in the United States rose from 30% in 1981 to 45% between 2000 and 2004 [37]. This increase in vaccination coverage was likely responsible for the 35% drop in acute hepatitis B incidence during that time (from 3.7 to 2.4 per 100,000 people) [37]. As a result, it is well known that the HBV vaccination offers excellent protection and that anyone who works in a position where they may come into contact with blood, bodily fluids tainted with blood, or sharp objects ought to get vaccinated against hepatitis B [38]. A 1- to 1.5-inch-long needle should ideally be used to inject the three standard doses of recombinant HBV vaccination intramuscularly in the deltoid region on a 0-, 1-, and 6-month schedule.

In order to prevent infection and the emergence of the carrier status, all HCWs should get vaccinated before the beginning of their career. They should follow a regular vaccination schedule, and 1–2 months after finishing the three-dose vaccine series, the blood levels of anti-HBs should be checked [39]. HCWs who engage in exposure-prone procedures (EPPs) are more likely to contract an infection. As a result, postvaccination testing is suggested to determine the situation of vaccinated HCWs. Ensuring early vaccination and timely antibody titer testing is not only beneficial to the HCW but also represents a critical public health measure that reduces patient risk in clinical practice.

In most countries, the anti-HBV vaccination of HCWs has been in place since the 1980s. All HCWs, including trainees, who have a high risk of occupational percutaneous or mucosal exposure to blood or bodily fluids should undergo postvaccination testing for antibodies to the anti-HBs. Testing should be done between one and two months following the last dosage of the vaccine. Postvaccination testing is probably not cost-effective for people who are at low risk of mucosal or percutaneous exposure to blood or bodily fluids (such as public safety personnel and HCWs who do not have direct patient contact); however, those who do not receive postvaccination testing should be advised to get tested right away if exposed [40].

Even though the vaccine has excellent immunogenicity, anti-HBs titers were less than 10 IU/mL in 20% of vaccination recipients. However, those who have been vaccinated against HBV and they have an anti-HBs titer of less than 10 IU/mL, or have developed an anti-HBs negative status can be regarded as immune to HBV infection because they may still have immunological memory for HBsAg. It would guarantee that, in the case of an HBV attack, protective antibody levels would quickly increase. This is for people who develop significant anti-HBs titer immediately after vaccination, but with anti-HBs titer that became negative or < 10 IU/mL thereafter. For people who never develop anti-HBs after vaccination the immune status is undetermined and probably less favorable [41]. However, low antibody titers against an HCW’s HBsAg titer may be overcome by a highly infectious HBV inoculum. Giving an additional dose of the HBV vaccine may be an option in those circumstances [42]. This emphasizes the importance of individualized follow-up strategies in occupational health, especially for HCWs with suboptimal vaccine response, to ensure continued protection and reduce nosocomial transmission risks.

Those who are at occupational risk of exposure to blood or body fluids might undergo anti-HBs testing upon recruitment. Figure 1 shows an algorithm for managing HCWs using documentation that revealed a completed HBV vaccination series with no documentation of anti-HBs titers of ≥ 10 mIU/mL [43, 44].

All HCWs should have an HBV vaccination, according to the 2012 CDC guidelines, and then have their levels of hepatitis B surface antibody (anti-HBs) checked. Additionally, revaccination is taken into consideration in cases of vaccine nonresponse. If the HCWs do not achieve protective levels of anti-HBs following a second three-dose series of the HBV vaccination, they should be tested for HBsAg and hepatitis B core antibody (anti-HBc) to find out whether they have ever been infected or have a chronic infection. Pre-vaccination serology is advised for HCWs who are sexually active men, who have sex with men, who conduct EPPs, and/or whose mothers are from endemic countries [45]. The United Kingdom Department of Health (UKDH) further suggests that all HCWs who do EPPs have an HBV vaccination and undergo postvaccination testing for an anti-HBs response. If the HCW does not respond to one series of vaccinations, they need to be checked for HBsAg, and if the result is negative, the HCW should also be tested for anti-HBc to ascertain whether he or she had previously been infected or is an actual vaccine nonresponder [46]. However, the 2003 European Consensus group recommendations urge all HCWs who come into contact with patients, blood, or other body fluids to receive an HBV vaccination, including a one-month post-immunization vaccine response test [47]. Nonresponders should have additional vaccinations, and if they still do not show any improvement, their HBV status should be looked into based on their line of work. These recommendations underline the need for tailored vaccination and testing strategies based on occupational exposure risk and local epidemiology. They also highlight the importance of establishing clear institutional policies for managing nonresponders.

The risk assessment and exposure score will determine, depending on the presence or not of anti-HBs titer > 10 mIU/mL post vaccination, if post-exposure prophylaxis is necessary or not, and whether to employ only active vaccination (HBV vaccine) or both active and passive immunization [hepatitis B immunoglobulin (HBIG)] [11]. Postexposure prophylaxis can be carried out with the HBIG, the HBV vaccination, or both. It must begin as soon as feasible, ideally 24 hours after exposure and no later than one week [48]. Management recommendations based on the testing results are shown in Table 2 [43].

Most of the management recommendations for HBV-infected HCWs are based on data coming from transmission of the HBV from HCW to patient, and they try ethically to strike a balance between the patient’s danger of becoming infected and the infected HCW’s right to perform their job safely without losing their confidentiality [4]. We should know that transmission of blood from HCWs to patients involves a double injury simultaneously in the patient and HCW and is therefore mostly observed in procedures with limited visibility. The proportion of patients who were infected after surgery with an infected surgeon [infected HCW (IHCW)] is between 0.5% and 13.1% [49].

The Society for Healthcare Epidemiology of America, in 2010, updated its recommendations and suggested that HCWs who have a positive HBeAg result and circulating HBV burden of 10⁴ genome equivalents (GE) per mL (roughly comparable to 8,000 IU/mL) of blood use double-gloving for all invasive procedures, for all contact with mucous membranes or nonintact skin, and for all patient care situations where gloving is advised. In contrast, for HCWs with a circulating HBV burden of < 10⁴ GE/mL of blood, it is recommended that providers perform all Category I, II, and III (minimal, low-risk procedures and high-risk procedures) provided they [50]:

(1) Did not infect patients with the HBV virus.

(2) Consult an expert review panel for guidance.

(3) Be subjected to regular occupational medicine follow-up, including testing for viruses twice a year, to ensure the viral load stays below 10⁴ GE/mL.

(4) Follow-up with a personal doctor with experience in treating HBV infections and who is permitted to consult with the expert review panel regarding the clinical condition of the HCW.

(5) Strictly follow recommended infection control techniques after consulting an expert.

(6) Accept and sign the expert review panel’s contract or letter outlining their obligations.

The CDC advised that HCWs with HBV infections should still be able to practice medicine, dentistry, surgery, and other allied healthcare professions [45]. If they have a low (1,000 IU/mL or 5,000 GE/mL) or undetectable HBV viral load and have been monitored every six months, HBV-infected HCWs who perform EPPs should continue to do so. The performance of EPPs should be limited if the viral load is higher than what is advised until further testing is done [45]. EPP stands for exposure-prone procedures. These are medical procedures that carry a risk of transmission of bloodborne pathogens from the HCW to the patient, especially when the HCW is infected with HBV. The distinction between EPPs and non-EPPs is shown in Table 3 [45].

The CDC also advises that organizations have established HBV-infected HCW management policies and procedures in place, including the capability to create an expert review panel to help with this management [45]. According to the UKDH, all HCWs who have a positive HBsAg test should also undergo an HBeAg test. HCWs with an HBV viral load greater than 10³ GE/mL, regardless of their HBeAg status (positive or negative), should not perform EPPs. Annual monitoring is recommended, and practice should not be limited if the HBeAg test is negative and the viral load is < 10³ GE/mL without antiviral therapy [51]. HBeAg-negative HCWs should be allowed to perform EPPs while on antiviral therapy as long as their viral load is at or below 10³ GE/mL on three-monthly monitoring and before treatment, viral load is at or below 10⁵ GE/mL, according to guidelines shared by the UKDH in 2007. Although the UKDH recommendations do not suggest creating an expert panel to direct the management of infected HCWs with HBV, they do suggest an occupational health physician’s involvement [51]. However, the 2003 European Consensus group recommendations said that HCWs should only be permitted to proceed with EPPs if their HBsAg test results are negative. HCWs who are HBsAg-positive should have their HBeAg levels tested; if the test is negative, they can do EPPs if their HBV DNA level is < 10⁴ GE/mL. Every year, the HBV DNA level should be checked. Unless their viral load is below the authorized cut-off and they are examined by an expert panel that has approved the performance of EPPs [52]. It should be specified that HCWs with a high viral load are authorized to engage in non-EPPs without inappropriate restrictions. Non-EPPs are procedures that do not pose a significant risk of transmitting infectious agents from the HCW to the patient. As long as appropriate infection control measures are followed. In fact, imposing unnecessary limitations on HCWs could lead to workforce shortages and may contribute to unnecessary stigmatization, especially when there is no clear evidence that such restrictions improve patient safety [45].

The 2017 European Association for the Study of the Liver (EASL) guidelines recommend that HBV infection alone should not disqualify infected persons from the practice or study of surgery, dentistry, medicine, or allied health fields [53]. Regular monitoring of HBV DNA levels is advised. If viral load is low (e.g., < 200 IU/mL according to some criteria), performing EPPs may be allowed under specific conditions. HCWs performing EPPs with serum HBV DNA > 200 IU/mL may be treated with NA to reduce transmission risk [53].

According to the 2018 American Association for the Study of Liver Diseases (AASLD) guidelines, performing EPPs is not permitted for HBV-infected HCWs if their serum HBV DNA level exceeds 1,000 IU/mL. However, they may resume such procedures once their viral load is reduced and maintained below this threshold [54]. These decisions should be made in consultation with an expert review panel, and institutional policies should be based on up-to-date evidence and individualized assessment rather than on blanket restrictions [54]. Reflecting on the different guidelines and recommendations provided, we find the ethical considerations to be the most complex aspect of managing HBV-infected HCWs. From my perspective, the balance between patient safety and the rights of HCWs is delicate. On one hand, HCWs must be protected from potential discrimination or unnecessary restrictions if they follow recommended guidelines and maintain low or undetectable viral loads. On the other hand, healthcare institutions must prioritize the safety of their patients, especially in high-risk procedures that could expose them to infection.

In my opinion, it’s crucial that the policies are not just based on broad standards but that they take into account the individual circumstances of each HCW, such as their viral load, adherence to treatment, and whether they have been adequately monitored. This individualized approach allows for more humane treatment of the HCWs, avoiding unnecessary stigma while ensuring that patient safety remains intact. Moreover, we think one of the key aspects that needs more emphasis is the role of the expert review panels. These panels provide an essential check-and-balance system, ensuring that the decision-making process is evidence-based and appropriately tailored to the situation at hand. They allow for more flexibility and precision in decision-making, which is especially important considering the variation in HBV load and the potential for new, evolving treatment options.

Finally, it was suggested in the 2012 Australian guidelines that HCWs be prohibited from doing EPPs if HBV DNA could be detected by an authorized polymerase chain reaction assay. The HCW may perform EPPs even if they are HBsAg-positive and receive antiviral medication if HBV DNA is undetectable by testing every three months. The HCW may administer EPPs if the HBsAg result turns negative twice in a row, but they should test the HBV DNA level regularly every year [47].