Hepatitis B Immunization among Healthcare Students: A Narrative Review of Occupational Risk, Long-Term Immunity, and Challenges in Multicultural Academic Settings

1. Introduction

Infection with the hepatitis B virus (HBV) remains one of the most significant preventable infectious diseases worldwide [1]. It is estimated that 254 million people were living with chronic hepatitis B virus (HBV) infection in 2022. Together, viral hepatitis B and C caused an estimated 1.3 million deaths that year, with HBV accounting for around 83% of this total [2,3]. HBV is a small, partially double-stranded DNA virus for which humans are the only relevant reservoir. This feature makes the infection potentially eradicable through sustained vaccination [4]. Based on this premise, the World Health Organization (WHO) has set targets to reduce new chronic hepatitis B virus (HBV) infections by 90% and HBV-related mortality by 65% by 2030, compared to 2015 levels [5]. A 2026 analysis of the global burden of chronic hepatitis B, based on Global Burden of Disease data, estimated 283.64 million prevalent cases in 2021 — an 8.3% decline from 1990 — and 431,960 deaths in 2021 alone. While most world regions showed declining age-standardised rates over this period, Eastern Europe, high-income North America and Central Asia showed stable or increasing trends. This highlights that progress towards the 2030 elimination target is uneven [6].

Despite the availability of an effective hepatitis B virus (HBV) vaccine since the early 1980s, and its progressive inclusion in national immunisation programmes, HBV transmission continues to pose a public health challenge in populations at elevated risk of occupational exposure [7]. Healthcare workers are among the professions most frequently exposed to bloodborne pathogens through needlestick injuries, contact with contaminated sharps and exposure of mucous membranes to blood and body fluids. Accordingly, hepatitis B vaccination has been a cornerstone of occupational health policy in healthcare settings for decades [8,9].

Within this broader picture, healthcare students represent a specific subpopulation of concern. During clinical training, students on medical, nursing, dental and allied health programmes begin to face occupational risks similar to those of qualified practitioners, despite having completed their primary hepatitis B virus (HBV) vaccination series in infancy or childhood many years earlier. Anti-hepatitis B surface antibody (anti-HBs) levels are known to decline over time, and vaccination coverage statistics alone do not accurately reflect the proportion of students who retain detectable protective titres by the time they enter clinical placements [10,11]. The increasing internationalisation of higher education exacerbates this uncertainty, as universities are enrolling a more diverse range of students with different vaccination schedules, documentation standards and natural exposure histories [12].

This narrative review aimed to synthesise the available evidence on hepatitis B immunisation among healthcare students. The review addressed three key areas: i) seroprotection and the persistence of long-term immunity in this population, ii) the evidence-based management of students with low or absent anti-HBs titres, and iii) the specific challenges posed by multicultural academic environments. Throughout, practical implications for occupational health services operating within university settings are discussed.

2. Materials and Methods

This article is a narrative review. A literature search was performed in PubMed/MEDLINE and Scopus, covering publications from January 2000 to December 2025. Where they provided foundational evidence, seminal studies predating this period were also considered. The reference lists of all included articles were screened for additional relevant sources.

The search strategy employed the following terms in various combinations: ("hepatitis B" OR "HBV") AND ("vaccination" OR "immunization" OR "anti-HBs" OR "seroprotection" OR "long-term immunity" OR "waning immunity" OR "booster" OR "non-responder" OR "anamnestic response" OR "antibody persistence") AND ("healthcare students" OR "medical students" OR "nursing students" OR "dental students" OR "health profession students" OR "healthcare workers" OR "occupational health") AND ("needlestick" OR "sharps injury" OR "occupational exposure" OR "post-exposure prophylaxis" OR "bloodborne pathogens" OR "fitness for duty" OR "multicultural" OR "international students"). No language restriction was applied.

Articles were considered eligible for inclusion if they addressed one or more of the following: seroprotection rates or antibody persistence following hepatitis B vaccination in healthcare students or workers; the clinical management of low or absent anti-HBs titres; the risk of occupational exposure and post-exposure prophylaxis in healthcare trainees; or immunisation challenges in multicultural or international academic settings. Opinion pieces and case reports were excluded unless they provided background data of direct relevance. A total of 49 references were selected for inclusion, 34 of which were identified as primary sources for the thematic synthesis presented in the 'Results' section.

3. Results

The following sections summarise the available evidence across four themes: the occupational exposure risk profile of healthcare students; the trajectory of vaccine-induced immunity and its long-term persistence; the clinical management of students with low or absent anti-HBs titres, including post-exposure prophylaxis; and the specific challenges posed by multicultural academic environments. A final section addresses the medicolegal implications of immunisation status in the context of fitness for clinical duty. Thirty-four references were selected as primary sources for the thematic synthesis.

3.1. Occupational Exposure Risk in Healthcare Students

Healthcare students are not merely at theoretical risk of occupational exposure to bloodborne pathogens; epidemiological data indicate that needlestick and sharps injuries (NSIs) occur at measurable rates during clinical training [13,14,15]. Studies examining occupational exposure events in tertiary hospitals have consistently identified medical students as being among the highest-risk groups, accounting for around 30% of all reported NSIs in some studies, alongside nurses and junior doctors [16]. The annual prevalence of needle stick injuries (NSIs) in nursing students has been reported as high as 13.9% in Australia [17] and approximately 18% in Italy [18], with considerable heterogeneity attributable to differences in surveillance systems, clinical activity volume and reporting culture [19]. NSIs predominantly occur during procedures such as the administration of injections, venepuncture and surgical assistance, and are most commonly located on the fingers. Hospital wards and operating theatres account for the majority of incidents [16]. A notable and persistent problem is underreporting: studies suggest that more than one-third of injured trainees do not formally report NSIs, most commonly citing inconvenience or concerns about the time reporting procedures require [20]. From a public health perspective, this underreporting is relevant, as unreported exposures may result in delayed or absent post-exposure evaluation and prophylaxis, with potential consequences for both the student and, in the case of HBV-infected trainees, patients.

3.2. Vaccine-Induced Immunity: Mechanisms and Expected Trajectory

The standard primary hepatitis B virus (HBV) vaccination series consists of three doses, typically administered at 0, 1 and 6 months. An anti-HBs concentration of ≥10 mIU/mL measured four to eight weeks after completing the series is internationally accepted as the threshold for seroprotection [21]. Initial seroconversion rates exceed 95% in healthy individuals who complete the full series, although this figure declines with increasing age at vaccination. Seroconversion rates are approximately 92% in adults under 40 years of age and around 84% in those over 40 years of age [10].

Long-term protection is primarily attributed to the persistence of immunological memory rather than to circulating antibody levels alone [22]. Long-term follow-up studies spanning 30 and 35 years have shown that protection against clinical hepatitis B virus (HBV) infection is maintained in the majority of vaccinated individuals, even after anti-HBs titres become undetectable. This is due to memory B cells and long-lived plasma cells that can mount a rapid anamnestic response when re-exposed to HBV antigens [23,24]. Following primary infant vaccination, the rate of antibody decline has been estimated at approximately −42.39 mIU/mL per year in a longitudinal cohort of healthcare workers and medical students vaccinated in infancy in Thailand. Seroprotection rates of 28%, 51.7% and 60% were observed at 16–20, 21–25 and 26–28 years post-vaccination, respectively [25]. The apparently nonlinear pattern of seroprotection across these intervals likely reflects survivor bias and intermediate revaccination in the study cohort rather than a true increase in naturally circulating antibodies over time and should be interpreted with caution. The distinction between antibody waning and loss of protection is the conceptual basis for interpreting seroprotection data in healthcare students, which is revisited below.

3.3. Seroprotection and Waning Immunity in Healthcare Students

Despite the high vaccination coverage reported in countries with long-standing universal childhood immunisation programmes, the proportion of healthcare students with protective anti-HBs levels at the time of pre-clinical screening varies considerably across studies. A systematic review and meta-analysis of 46 studies involving 52,749 healthcare students from highly developed countries found a pooled seroprotection prevalence of 73.8% (95% confidence interval [CI]: 69.1–78.0) at the pre-exposure assessment. This indicates that over one in four students had anti-HBs levels below the protective threshold when they started clinical training [11]. Meta-regression analyses from the same study identified time elapsed since vaccination and the proportion of students vaccinated in infancy rather than adolescence as significant negative predictors of seroprotection.

Findings from individual cohort studies are broadly consistent with this pooled estimate, while illustrating substantial heterogeneity in terms of setting, geographic context and time since vaccination. A four-year retrospective study of 2,028 healthcare trainees at a central Italian hospital reported an overall seroprotection prevalence of 50.7%. Protective immunity was observed in 79.2% of students who were vaccinated during adolescence, compared to 44.6% of those who were vaccinated in infancy (p < 0.001). This result reinforces the idea that age at vaccination is a key determinant of residual antibody levels [26]. A separate cross-sectional study of 507 health profession students at an international, multi-ethnic university found overall seroprotection in only 55.0% of participants, with lower rates among those vaccinated in infancy and born outside Europe after adjusting for time since the last dose [12]. In a South African university setting, baseline screening before a booster intervention found that 56% of healthcare students were non-immune, a figure consistent with lower rates reported in European cohorts. This underscores the fact that inadequate seroprotection at the start of clinical training is not confined to high-income Western settings [27]. Taken together, these studies suggest that the proportion of students who can be assumed to be seroprotected without testing is determined by vaccination timing, geographic and demographic background, and time since the primary series.

Antibody waning is a well-documented and expected phenomenon, rather than being evidence of vaccine failure. A study of 734 Italian healthcare workers and medical students who were vaccinated in infancy or adolescence found that 12.0% of subjects (88/734) had a non-protective anti-HBs titer. Of those who received a booster dose, almost 90% had a protective titer one month later, indicating that the initial low titers were due to the physiological decline of antibodies over time rather than vaccine failure [10]. A national meta-analysis of 19 studies on Italian healthcare workers estimated an overall hepatitis B sero-susceptibility prevalence of 27.1% (95% CI: 23.2–31.7), with a markedly lower risk among those vaccinated in adolescence compared to those vaccinated in infancy (relative risk: 0.30; 95% CI: 0.25–0.37) [28]. A separate cohort study of 539 healthcare workers who had been vaccinated up to 30 years previously found that the rate of subsequent anti-HBs loss differed sharply according to the magnitude of the initial post-vaccination response: There were 52.1 losses per 1000 person-years among poor responders (initial anti-HBs 10–99 mIU/mL), compared with 11.3 among moderate responders, and just 1.4 among good responders (≥1000 mIU/mL). This identified the peak post-vaccination titer as the strongest predictor of long-term seroprotection [29]. These findings are consistent with longitudinal quantitative data from Thailand, where the overall rate of anti-HBs decline following primary infant vaccination was estimated at −42.39 mIU/mL per year, and with the immunological memory framework. The meta-analysis by Rahmani et al. found that 90.9% (95% CI 87.7–93.3) of students with non-protective anti-HBs at pre-exposure screening mounted a demonstrable anamnestic response after a single booster dose. Only 5.0% (95% CI 2.1–11.5) were classified as true non-responders after a complete second vaccination cycle [11,25]. Accordingly, current WHO and ACIP guidance holds that a decline in anti-HBs below 10 mIU/mL, in the absence of documented exposure, does not indicate susceptibility to infection [21,23].

3.4. Management of Low or Absent Anti-HBs Titres

The most commonly encountered finding in healthcare students during pre-clinical occupational health screening is the detection of anti-HBs below 10 mIU/mL. This calls for a stepwise, evidence-based response rather than assuming susceptibility. An algorithm synthesised from current guidance is summarised in Table 1.

For students with a documented complete primary series who have non-protective anti-HBs levels, the guidelines recommend a single booster dose, followed by serological retesting after four to eight weeks [30,31]. As mentioned above, the vast majority of individuals who have previously been vaccinated demonstrate an anamnestic response to this challenge dose. A retrospective observational study of healthcare students in Japan validated this stepwise approach in a real-world setting. The study found that revaccination management tailored to prior vaccination history yielded effective seroconversion in the majority of participants. This supports the clinical utility of vaccination-history-guided protocols over uniform revaccination strategies [32]. Students who do not respond to the booster are classified as potential primary non-responders and should receive a full second series of three doses. Those who remain seronegative after this are classified as definitive non-responders [11,28,29]. These individuals require specific counselling on post-exposure prophylaxis, including access to hepatitis B immunoglobulin in the event of occupational exposure. They may also be subject to risk-based restrictions on certain clinical activities within institutional frameworks.

For the small proportion of students who remain unprotected after two full vaccination series, multivalent vaccine formulations incorporating the preS1 and preS2 surface antigens produced in mammalian cell lines have been shown to be effective in inducing seroprotection where conventional yeast-derived recombinant vaccines have failed [33]. These formulations are licensed in several countries and are a viable option for definitive non-responders, although they are not widely integrated into routine occupational health protocols at universities.

Prompt evaluation is required for occupational exposure to blood or body fluids, and post-exposure prophylaxis (PEP) should be administered where indicated. For hepatitis B virus (HBV) specifically, the immunological status of the exposed individual at the time of the incident is the primary determinant of the appropriate management pathway. Healthcare students with documented seroprotection (anti-HBs ≥10 mIU/mL) following vaccination do not require specific HBV-directed prophylaxis after occupational exposure, regardless of the HBsAg status of the source patient [31]. Students with no documented anti-HBs or classified as non-responders require different management depending on the HBsAg status of the source. If the source is HBsAg-positive or the status is unknown, hepatitis B immunoglobulin (HBIG) should be administered as soon as possible, ideally within 12–24 hours of exposure and no later than seven days, as its efficacy beyond this timeframe is uncertain [34,35,36,37]. Unvaccinated students should initiate the full primary vaccination series simultaneously. Those who are true non-responders and have already completed two vaccination series, yet remain seronegative, should receive two doses of HBIG (0.06 ml/kg) if the source is HBsAg-positive [34,35,36,37]. These pathways emphasise the importance of pre-exposure serological screening in practice: if a student's vaccination status and anti-HBs level are documented at the time of an incident, they can be managed quickly and appropriately. However, the absence of this information can lead to delays and may result in unnecessary or suboptimal prophylaxis. Therefore, the management of post-exposure situations provides an additional and often overlooked rationale for systematic serological assessment at the start of clinical training.

Table 2 summarises the recommended management pathways according to the student's immunological status and the HBsAg status of the source.

3.5. Challenges in Multicultural and International Student Populations

The internationalisation of higher education introduces additional heterogeneity into the immunisation profiles of healthcare student cohorts. Students arrive from countries with markedly different hepatitis B virus (HBV) epidemiology, vaccination schedules (including birth-, infant-, or adolescent programmes), vaccine quality, cold chain standards, and documentation practices. This complicates any assumption that self-reported vaccination history is a reliable basis for risk classification [38,39]. This heterogeneity has also been well documented among qualified healthcare personnel. Reported HBV vaccination coverage among healthcare workers has been estimated at only 18% in parts of Africa, compared to 77% in Australia and New Zealand, around 82% in Egypt, and 80% in South Africa. This illustrates the scale of disparity that international student cohorts may introduce when self-reported history is used to infer protection, rather than serological testing [40,41,42]. Differences in the seroprevalence of naturally acquired immunity among students from intermediate- or high-endemicity regions further complicate the interpretation of anti-HBs results, since a positive titer may reflect either vaccination or past infection.

Data from the multi-ethnic university cohort discussed above illustrate this directly. Students of non-European origin showed significantly lower seroprotection than their European-born counterparts, even after adjusting for age at vaccination and time since the last dose. This suggests that factors beyond the timing of vaccination alone, including vaccine type, adherence to the vaccination schedule, and the quality of the healthcare system in the country of origin, contribute to the immunological profile of international students [12]. A similar finding in South Africa, where 56% of healthcare students were non-immune at baseline despite national infant vaccination programmes, demonstrates that the discrepancy between vaccination coverage and seroprotection levels upon entering clinical training is a global phenomenon rather than a peculiarity of specific national contexts [27]. Interpreting anti-HBs results in students from intermediate- or high-endemicity regions is further complicated by the potential presence of naturally acquired immunity: anti-HBc positivity in the absence of HBsAg may indicate a resolved infection rather than protection induced by vaccination. These students should not be assumed to be at increased risk of reinfection, but their immune status should nonetheless be formally documented.

A practical response to this heterogeneity is to conduct universal serological screening upon entry to clinical training, encompassing anti-HBs, HBsAg and anti-HBc, for all incoming students, regardless of their self-reported vaccination history [26]. This three-marker approach distinguishes four relevant groups: students with vaccine-induced seroprotection, who require no further action; susceptible students, who require vaccination; students with naturally acquired immunity (anti-HBc positive and HBsAg negative), who are protected, but whose infection history should be documented; and students with chronic HBV infection (HBsAg positive), who require clinical referral. For students without any vaccination documentation, it is pragmatic to administer the complete primary series and verify seroconversion serologically, treating an undocumented history as equivalent to no prior vaccination.

3.6. Fitness for Duty Assessment: The Italian Framework and Its International Relevance

In Italy, the occupational health assessment of healthcare students and workers is governed by Legislative Decree 81/2008 (the Consolidated Act on Occupational Health and Safety). Article 279 of this decree stipulates that workers exposed to biological agents must undergo health surveillance, and that effective vaccines must be made available to those who are not already immune. The occupational physician (medico competente) is responsible for determining fitness for duty (giudizio di idoneità alla mansione specifica) in relation to the biological risk profile of the clinical role. In the context of hepatitis B, vaccination status and serological response directly inform this assessment. A healthcare student who is a documented non-responder or who refuses vaccination without a valid medical contraindication may receive a restricted fitness judgement. For example, they may be excluded from invasive procedures carrying a high risk of blood exposure. Alternatively, if no alternative clinical assignment is practicable, they may be given a temporary judgement of unfitness for the specific role [29,43]. This medico-legal mechanism, which links immunisation status directly to access to clinical training, has no direct equivalent in most other European countries, where institutional policies on vaccination for healthcare students are highly variable and often non-binding. Nevertheless, the underlying principle — that documented susceptibility to a preventable blood-borne pathogen should have operational consequences within an occupational health framework — is an increasingly discussed topic in the international literature, particularly in the context of strengthening occupational vaccination programmes for healthcare trainees [41]. The Italian model may therefore serve as a useful reference for institutions and regulators in other countries seeking to formalise the relationship between pre-clinical immunisation screening and access to clinical placements.

4. Discussion

The evidence reviewed here suggests that, while universal childhood vaccination is highly effective at the population level, it cannot be assumed to provide uniform protection among healthcare students at the start of their clinical training. Pooled data suggest that approximately one in four students in highly developed countries has anti-HBs levels below the protective threshold at pre-clinical screening. Individual cohort studies report seroprotection rates of 50–55% in specific settings, particularly in cases where a large proportion of students were vaccinated in infancy or come from outside the country in which they are training [10,11,12,26]. This differs significantly from the reassurance that high national vaccination coverage figures might otherwise suggest, and has direct implications for how occupational health services plan pre-clinical screening, rather than relying on vaccination certificates alone.

At the same time, the high prevalence of anamnestic responses following a single booster dose — exceeding 90% in the largest available meta-analysis — suggests that low anti-HBs levels at screening are primarily indicative of waning circulating antibodies rather than lost immunity [11]. This distinction is important in practice: it suggests that revaccinating all students with low titres is unnecessary for most and supports the stepwise approach outlined in Table 1, where a booster is followed by a retest, with full revaccination reserved for those who do not respond.

The findings on multicultural cohorts raise a question that the current literature has not yet fully answered: does the lower seroprotection observed among internationally born students reflect timing and documentation gaps in vaccinations that could be resolved with better records, or are there more permanent differences in the type of vaccine used, the completeness of the vaccination schedule, or the population-level immune response that would persist even with perfect documentation? Existing studies are largely cross-sectional and drawn from single institutions, which limits causal inference and generalisability across different national contexts [12,26]. Similarly, much of the evidence on long-term persistence comes from cohorts vaccinated decades ago under immunisation schedules that differ from those in use today. An exception is the longitudinal quantification of the decline rate of anti-HBs in Thai healthcare trainees, which provides rare time-resolved data on the trajectory of waning immunity [25]. However, even this study is subject to survivor bias inherent in cohorts where intermediate revaccination events cannot always be systematically excluded. Prospective longitudinal designs with complete documentation of vaccination histories will be necessary to definitively resolve these uncertainties.

Another important consideration with direct implications for surveillance and post-exposure management is the substantial and persistent underreporting of occupational exposure events among healthcare students. Across studies, the proportion of needlestick and sharps injuries that go unreported ranges from approximately 19% to over 80%, with nursing students exhibiting particularly high rates of non-disclosure. Barriers identified include the perception that the injury was minor or the risk negligible, unfamiliarity with reporting procedures, time pressure and, specifically in the context of students, fear that reporting might negatively affect academic evaluations or relationships with supervisors [20,44]. This last barrier is particularly consequential for trainees, who are in a position of institutional dependency unlike qualified employees. In the context of hepatitis B specifically, the clinical relevance of underreporting is that delayed or absent reporting can prevent timely post-exposure serological assessment and, where indicated, the initiation of HBIG within the critical 12–24 hour window [34]. Therefore, occupational health services and academic institutions should address underreporting as both a surveillance gap and a patient safety issue. This can be achieved through clear, non-punitive reporting pathways, proactive communication of procedures at the start of each clinical rotation, and explicit reassurance that reporting an exposure will not have any academic consequences.

The psychological consequences of needlestick and sharps injuries are a dimension of occupational risk that is systematically underaddressed in the management of occupational health for healthcare students. Studies conducted in hospital settings have found that over 80% of healthcare workers who experience an occupational exposure report anxiety in the immediate aftermath, with a significant proportion experiencing clinically significant distress throughout the serological follow-up period [46]. Post-traumatic stress disorder following high-risk exposure, particularly involving sources with known chronic viral infections, has been described in the literature. Some affected individuals report persistent behavioural changes, including avoidance of certain clinical procedures [13,46]. In the student population, these effects may be exacerbated by a lack of experience with the post-exposure process, uncertainty regarding confidentiality and worries about how the event will affect their academic career. Pre-existing seroprotection, as confirmed by pre-clinical serological screening, can substantially reduce the psychological burden of occupational exposure. A student entering clinical training with documented anti-HBs ≥10 mIU/mL can be reassured that no hepatitis B virus (HBV)-directed prophylaxis is required in the event of exposure. In contrast, a student with an unknown or non-protective serological status faces a more complex and anxiety-inducing post-exposure pathway. This represents a further, often overlooked, argument in favour of systematic pre-clinical immunisation assessment.

Educational and training interventions targeting healthcare students have demonstrated measurable effectiveness in reducing the incidence of needlestick injuries and improving vaccination compliance and post-exposure management behaviour. A Cochrane-registered systematic review of education and training programmes for preventing sharps injuries in healthcare workers found that structured interventions significantly improved knowledge of post-exposure procedures. In one controlled study, these interventions increased hepatitis B vaccination uptake among nursing staff from 71.4% to 91.8%. Studies specifically targeting students have found that, while knowledge of bloodborne virus transmission is generally adequate, adherence to safe practice — including needle disposal, recapping avoidance, and prompt injury reporting — remains suboptimal and cannot be reliably predicted by knowledge alone [47,48]. This discrepancy between knowledge and behaviour highlights the need for training programmes incorporating supervised practical components, simulation-based skill acquisition and explicit instruction on reporting culture, rather than didactic knowledge transfer alone. Ideally, training on safe sharps handling, post-exposure pathways and the importance of pre-clinical immunisation verification should be delivered at the start of each clinical placement and updated at the beginning of each new academic year.

From a health economics perspective, the cost-effectiveness of pre-clinical hepatitis B serological screening in healthcare students is unclear and hinges critically on assumptions about the long-term protective efficacy of the primary vaccine series and local occupational hepatitis B virus (HBV) exposure rates. A formal modelling study conducted in the United States evaluated the incremental cost-effectiveness of a pre-exposure serological evaluation followed by additional vaccinations for trainees without protective anti-HBs. The study found that the incremental cost-effectiveness ratios ranged from approximately $144,000 to over $800,000 per QALY, depending on the assumed level of long-term vaccine protection [49]. While these figures exceed conventional cost-effectiveness thresholds under the assumption of 95% long-term protection, they approach or cross acceptable thresholds when the real-world protection rate is closer to 68% — a scenario that is more consistent with the seroprotection data reviewed in this article. These data indicate that a substantial proportion of students present with non-protective anti-HBs at the start of their training. Therefore, the economic argument for universal pre-clinical screening is strengthened by the evidence that long-term protection rates in current student cohorts are lower than previously assumed, particularly among those vaccinated in infancy and in international student populations. These considerations suggest that the question should be reframed from 'Is screening cost-effective compared to doing nothing?' to 'What is the cost of not knowing a student's serological status at the time of a post-exposure incident?'. This may be a more policy-relevant approach to the economic evaluation of pre-clinical immunisation surveillance.

These limitations highlight clear priorities for future research: prospective, multinational, longitudinal studies tracking anti-HBs kinetics and anamnestic responses in cohorts vaccinated under contemporary schedules; and comparative evaluations of screening and revaccination strategies across institutions with different student demographics. In the meantime, the available evidence suggests that universal three-marker serological screening (anti-HBs, HBsAg and anti-HBc) upon entry to clinical training is the most reliable basis for making individualised immunisation decisions, rather than relying on vaccination history alone.

5. Conclusions

Hepatitis B immunisation among healthcare students is a multidimensional occupational health issue that goes beyond statistics on vaccine coverage. This review highlights several findings with direct practical relevance for occupational health services in university healthcare settings.

Despite high childhood vaccination coverage, a significant proportion of students — pooled estimates suggest approximately one in four, rising to nearly one in two among those vaccinated in infancy — have non-protective anti-HBs titres when they start clinical training. The majority of these students retain immunological memory and respond to a single booster dose. Evidence-based, stepwise management can effectively identify the small proportion of true non-responders, who require specific counselling and post-exposure prophylaxis planning. A student's documented immunisation status also determines the post-exposure pathway following occupational exposure. In some regulatory frameworks, it directly informs the assessment of fitness for clinical duty — a consequence that provides a compelling rationale for universal three-marker serological screening (anti-HBs, HBsAg and anti-HBc) at the start of training, rather than relying on self-reported vaccination history.

Needlestick injuries occur at measurable rates during clinical training, but are substantially underreported, particularly among students. This compromises both surveillance and timely post-exposure management. Structured educational interventions addressing safe sharps handling, reporting culture and post-exposure procedures have been shown to be effective and should be systematically integrated into pre-clinical training. International student cohorts require additional flexibility in screening protocols, as documentation alone cannot adequately capture heterogeneous vaccination histories and natural immunity profiles.

Collectively, these findings support a proactive, integrated approach to hepatitis B immunisation surveillance in healthcare education. This approach would contribute to the WHO's 2030 viral hepatitis elimination agenda by ensuring that future healthcare professionals enter practice with verified, documented protection.