Guidance for Industry 
 
 
Requalification Method for Reentry of 
Donors Who Test Hepatitis B Surface 
Antigen (HBsAg) Positive Following a 
Recent Vaccination against Hepatitis B 
Virus Infection 
                  
 
This guidance is for immediate implementation
 
FDA is issuing this guidance for immediate implementation in accordance with 21 CFR 
10.115(g)(4)(i).  Submit one set of either electronic or written comments on this guidance at 
anytime.  Submit electronic comments to http://www.regulations.gov.  Submit written comments 
to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 
Fishers Lane, Rm. 1061, Rockville, MD 20852.  You should identify all comments with the 
Docket No. FDA-2011-D-0829 for this guidance. 
 
Additional copies of this guidance are available from the Office of Communication, Outreach 
and Development (OCOD), (HFM-40), 1401 Rockville Pike, Suite 200N, Rockville, MD 20852-
1448, or by calling 1-800-835-4709 or 301-827-1800, or e-mail ocod@fda.hhs.gov, or from the 
Internet at 
http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guida
nces/default.htm. 
 
For questions on the content of this guidance, contact OCOD at the phone numbers or e-mail 
address listed above. 
 
 
 
U.S. Department of Health and Human Services 
Food and Drug Administration 
Center for Biologics Evaluation and Research 
November 2011 
    Contains Nonbinding Recommendations 
 
 
 
 
 
TABLE OF CONTENTS 
 
I.  INTRODUCTION.......................................................................................................................2 
 
II.  BACKGROUND.........................................................................................................................2 
 
III.   RECOMMENDATIONS...........................................................................................................5 
 
IV.   IMPLEMENTATION................................................................................................................7 
 
V.  REFERENCES............................................................................................................................8 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  i Contains Nonbinding Recommendations 
Guidance for Industry 
 
Requalification Method for Reentry of Donors Who Test Hepatitis B 
Surface Antigen (HBsAg) Positive Following a Recent Vaccination 
against Hepatitis B Virus Infection 
 
This guidance represents the Food and Drug Administrations (FDAs) current thinking on this 
topic.   It does not create or confer any rights for or on any person and does not operate to bind 
FDA or the public. You can use an alternate approach if the approach satisfies the requirements 
of the applicable statutes or regulations.  If you want to discuss an alternate approach, contact 
the appropriate FDA staff.  If you cannot identify the appropriate FDA staff, call the appropriate 
number listed on the title page of this guidance. 
 
 
I.  INTRODUCTION 
 
This guidance document is intended for blood establishments that manufacture Whole Blood and 
blood components for transfusion or for further manufacture, including Source Plasma and 
Source Leucocytes.  This guidance provides recommendations for a requalification method or 
process for the reentry of deferred donors who test repeatedly reactive for hepatitis B surface 
antigen (HBsAg), confirmed positive by neutralization, following a recent vaccination against 
hepatitis B virus (HBV) infection, and who are not infected by HBV.       
 
FDA issued a memorandum to all registered blood establishments on December 2, 1987, entitled, 
Recommendations for the Management of Donor and Donations that are Initially Reactive for 
Hepatitis B Surface Antigen (HBsAg) (FDA 1987 Memorandum) (Ref. 1).  This guidance 
supplements the FDA 1987 Memorandum. 
 
FDAs guidance documents, including this guidance, do not establish legally enforceable 
responsibilities.  Instead, guidance documents describe FDAs current thinking on a topic and 
should be viewed only as recommendations, unless specific regulatory or statutory requirements 
are cited.  The use of the word should in FDA's guidance documents means that something is 
suggested or recommended, but not required. 
 
 
II.  BACKGROUND 
 
Under Title 21 Code of Federal Regulations 610.40(a) (21 CFR 610.40(a)), you, blood 
establishments that collect blood and blood components, must test each donation of human blood 
or blood component intended for use in preparing a product for evidence of infection due to 
certain communicable disease agents, including HBV.  Under  610.40(h)(1), you must not ship 
or use human blood or blood components that have a reactive screening test for evidence of 
infection due to communicable disease agents, including HBV infection, except under certain 
circumstances.  Similarly, donors that test reactive for HBV must be deferred, with certain 
  2 Contains Nonbinding Recommendations 
exceptions ( 610.41(a)).  Note that under  610.41(b), a deferred donor subsequently may be 
found to be suitable as a donor of blood or blood components by a requalification method or 
process found acceptable for such purposes by FDA.  Such a donor is considered no longer 
deferred. 
 
The recommendations in the FDA 1987 Memorandum established procedures for reevaluating 
donors who were repeatedly reactive for HBsAg.  This guidance supplements the FDA 1987 
Memorandum by providing recommendations for a requalification method for reentry of 
deferred donors who test repeatedly reactive for HBsAg, confirmed by neutralization, following 
a recent vaccination against HBV, and who are not infected with HBV.   
 
A.  Prevalence, Transmission, and Testing for HBV Infection  
 
1.  Prevalence of HBV Infection 
 
HBV infection is a severe global health problem due to its high 
prevalence.  The world-wide number of infected individuals is estimated 
to be over 2 billion, and more than 400 million are in the chronic phase of 
infection (Ref. 2).  In the United States (U.S.), approximately 200,000 to 
300,000 acute HBV infections occur each year, more than 1 million 
individuals have chronic HBV infection and approximately 5,000 
individuals die each year from HBV induced hepatocellular carcinoma and 
chronic liver disease (Refs. 3 and 4).  Antigens and antibodies associated 
with HBV infection include HBsAg and antibody to HBsAg (anti-HBs), 
hepatitis B core antigen (HBcAg) and antibody to HBcAg (anti-HBc), and 
hepatitis B e antigen (HBeAg) and antibody to HBeAg (anti-HBe).  
Currently, all donations of Whole Blood and blood components and 
Source Plasma are tested for HBsAg.  The average time from exposure to 
detection of HBsAg is 30 days (range: 6 to 60 days) (Refs. 5 and 6). 
    
2.  Transmission of HBV Infection 
 
HBV can be transmitted by blood transfusion, through puncture wounds 
acquired during work in the health-care field (medical, dental, laboratory 
or other), by sharing needles used for injection of drugs, and by 
unprotected sex with an HBV infected partner (Ref. 2).  It has also been 
suggested that there is a possibility of HBV transmission through breast 
milk, as HBV markers such as HBsAg and HBV deoxyribonucleic acid 
(DNA) are detected in breast milk (Ref. 7).  However, studies have shown 
that there is no increased risk of HBV transmission from infected mothers 
to their children through breast-feeding (Ref. 8).   
 
3.  Testing for HBV Infection 
 
In accordance with  610.40(a)(3), each donation of blood and blood 
components must be tested for infection with HBV.  Consistent with the 
  3 Contains Nonbinding Recommendations 
FDA 1987 memorandum, donations of Whole Blood and blood 
components for transfusion are tested for HBsAg and anti-HBc.  All 
Source Plasma collections in the U.S. are tested for HBsAg.  However, 
FDA does not recommend that Source Plasma donors be tested for anti-
HBc because plasma units that are untested, non-reactive or repeatedly 
reactive for anti-HBc are currently acceptable for manufacture of plasma 
derivatives.  Under  610.41(a)(4), a deferred donor, who otherwise is 
determined to be suitable for donation and tests reactive for anti-HBc may 
serve as a donor of Source Plasma.  Under  610.40(h)(2)(v), anti-HBc 
reactive donations, otherwise non-reactive when tested as required under 
this section, may be used for further manufacturing into plasma 
derivatives. 
 
In addition, excluding anti-HBc reactive units in certain plasma products 
might compromise the safety of those products.  Anti-HBc and anti-HBs 
usually occur together in pools used for the manufacture of plasma 
derivatives.  If anti-HBc reactive units were excluded from these pools, 
titers of anti-HBs in the pools would be expected to diminish.  Because the 
presence of neutralizing anti-HBs is believed to contribute to the safety of 
certain plasma products such as immunoglobulins, reducing the titers of 
anti-HBs would have a negative effect on the safety of these products.     
   
B.  Rationale for Requalification Method for Reentry of Deferred Donors Who 
Test Repeatedly Reactive for HBsAg Following Hepatitis B Vaccination 
 
Hepatitis B vaccination has been shown to be a very effective measure to prevent 
HBV infection (Ref. 9).  Since 1982, recommendations for hepatitis B vaccination 
have evolved into a comprehensive strategy to eliminate HBV transmission in the 
U.S. (Refs. 10, 11, and 12).  These recommendations advise the vaccination of 
adults at risk for HBV infection as well as neonates, older children and 
adolescents.   
 
Currently manufactured HBV vaccines consist of recombinant antigenic, non-
infectious HBsAg protein that elicits production of protective, neutralizing, anti-
HBs when injected into individuals.  As viral HBsAg forms the outer envelope of 
HBV, anti-HBs neutralizes HBV, thus providing protection to the vaccinated 
individual from HBV infection.  Recombinant, non-infectious HBsAg from the 
vaccine remains in the circulation for several weeks after vaccination.  This 
circulating, non-infectious recombinant HBsAg tests repeatedly reactive using 
screening tests for HBsAg, and it is confirmed positive by HBsAg neutralizing 
tests.  Consequently, many donors who have been vaccinated against HBV and 
who do not have hepatitis B infection are deferred.  The deferral of non-infected 
hepatitis B vaccinated individuals is consistent with the FDA 1987 memorandum 
(Ref. 1).  
 
Following hepatitis B vaccination, HBsAg can be transiently detected in blood for 
  4 Contains Nonbinding Recommendations 
up to 21 days in neonates (Ref. 13) and up to 18 days in adults (Refs. 14 and 15).  
In these cases, the presence of HBsAg in the vaccine recipients does not signify 
infection with HBV, as anti-HBc and HBV DNA are not detectable and there are 
no clinical signs and symptoms of viral hepatitis.  Based on the transient detection 
of HBsAg, a deferral period of 28 days after the date of Hepatitis B vaccination 
should rule out the possibility of a positive screening test due to the vaccination.  
However, if vaccination has been given to a previously exposed individual 
(exposure by needle stick, risk behavior, etc.) as a prophylactic measure, a non-
reactive test result for HBsAg up to a period of 28 days after exposure does not 
necessarily rule out HBV infection.   
 
Based on the possibility of a positive screening test due to Hepatitis B 
vaccination, FDA is providing recommendations for a requalification method for 
reentry of donors deferred due to repeatedly reactive screening tests for HBsAg, 
confirmed by neutralization, following a recent vaccination against HBV, and 
who are not infected with HBV. 
 
 
III.  RECOMMENDATIONS 
 
Consistent with FDA 1987 Memorandum, a donor who tests repeatedly reactive for HBsAg, is 
confirmed positive by neutralization1, and who tests non-reactive for anti-HBc, is permanently 
deferred and the donation must not be used (Ref. 1).  Donors may be informed of the possibility 
for reentry based on Hepatitis B vaccination history when they are notified of their deferral.  
 
A.  When Hepatitis B vaccination was given for protection from possible future 
exposure or as a part of an approved Source Plasma HBV immunization 
program: 
 
The donor would be eligible for reentry 56 days after the donation that tested 
repeatedly reactive for HBsAg and confirmed positive by neutralization2, if:  
 
1.  The blood establishment determines that the donor received the 
vaccination against HBV infection within 28 days prior to collection of the 
specimen that tested confirmed positive for HBsAg; 
                                                 
1Some HBV NAT assays received a limited supplemental indication for repeatedly reactive HBsAg test results.  If a 
donor tests HBsAg repeatedly reactive and positive for HBV DNA using an HBV NAT with such a limited 
supplemental test indication, the HBsAg test result can be considered as HBsAg positive without performing HBsAg 
neutralization. These test results are indicative of HBV infection and are not caused by Hepatitis B vaccination.  
Therefore, such a donor should be deferred permanently.  If a donor tests HBsAg repeatedly reactive in a screening 
test and negative for HBV DNA using an HBV NAT with such a limited supplemental test indication, an HBsAg 
neutralization test should be performed.  The result of the neutralization test serves as the test of record.  
2 While not yet eligible for routine donation, Source Plasma donors actively participating in an approved HBV 
immunization program may be eligible for reentry into the HBV immunization program prior to 56 days, provided 
the donor tests non-reactive for HBsAg and all other donor suitability criteria are met at the time of the next 
donation. 
  5 Contains Nonbinding Recommendations 
2.  The vaccination was given solely to protect the donor from possible HBV 
infection because of potential future exposure to HBV or as part of an 
approved HBV immunization program for Source Plasma donors (i.e., it 
was not performed for the purpose of HBV infection prophylaxis 
following a specific incident of potential exposure, such as needlesticks, 
risk behavior, etc.); and 
3.  All other donor suitability criteria are met when the donor presents to 
donate. 
Additional testing (for the purpose of reentry) prior to the next donation is not 
recommended.   
B.  When Hepatitis B vaccination was given as a prophylaxis following a specific 
incident of potential exposure:  
 
The donor would be eligible for reentry after the donation that tested repeatedly 
reactive for HBsAg and confirmed positive by neutralization, if: 
 
1.  The blood establishment determines that the donor received the 
vaccination against HBV infection within 28 days prior to collection of the 
specimen that tested confirmed positive for HBsAg for the purpose of 
HBV infection prophylaxis following a specific incident of potential 
exposure; 
 
2.  A follow up sample, collected at least 12 months after the potential 
exposure, tests non-reactive for HBsAg, non-reactive for anti-HBc and 
negative for HBV DNA by individual donation (ID) NAT; and  
 
3.  All other donor suitability criteria are met when the donor presents to 
donate.    
 
Note: 
 
1)  A donation that tests repeatedly reactive for HBsAg should not be used, whether or 
not it is confirmed positive.  
 
2)  If test results for anti-HBc are repeatedly reactive, whether or not HBsAg test results 
are positive, refer to FDAs published recommendations and guidance (Refs. 16 and 
17). 
 
3)  A donor who was deferred because of previous HBsAg test results, whether or not 
these test results were caused by infection with HBV, may donate Source Plasma for 
use in the preparation of Hepatitis B Immune Globulin (Human), provided the current 
donation tests non-reactive for HBsAg and the donor is otherwise determined to be 
suitable ( 610.41(a)(3)). 
 
  6 Contains Nonbinding Recommendations 
 
IV.  IMPLEMENTATION 
 
We consider the recommendations in this guidance to be an acceptable requalification method or 
process, within the meaning of  610.41(b), for reentry of donors deferred due to repeatedly 
reactive screening tests for HBsAg, confirmed positive by neutralization, following a recent 
vaccination against HBV. 
 
Licensed establishments implementing these recommendations must report this change to FDA 
as required under 21 CFR 601.12(a).  We consider implementation of recommendations in this 
guidance in their entirety and without modification to be a minor change to an approved license 
application. Therefore, licensed establishments are not required to have FDA prior approval and 
may submit a statement of this change in an annual report under  601.12(d), indicating the date 
that the revised standard operating procedures were implemented.  Unlicensed establishments 
implementing recommendations in this guidance in their entirety and without modification are 
not required to report this change.  
 
Section 610.41(b) requires that a donor requalification method or process used to requalify a 
donor be acceptable to FDA.  Accordingly, before you implement an alternative requalification 
method or process from that described in this guidance, FDA must first find the alternative method 
or process to be acceptable for such purpose.  Licensed establishments intending to use an 
alternative requalification method must submit a supplement for prior approval, as required 
under  601.12(b). Similarly, FDA must find an alternative requalification method proposed by 
an unlicensed establishment to be acceptable before it is implemented. 
   
  7 Contains Nonbinding Recommendations 
 
V.  REFERENCES 
 
 
1.  FDA Memorandum to All Registered Blood Establishments: Recommendations for the 
Management of Donor and Units that are Initially Reactive for Hepatitis B Surface Antigen 
(HBsAg), December 2, 1987. 
 
2.  Lai, CL, et al., Viral Hepatitis B.  Lancet 2003; 362:2089-94. 
 
3.  Margolis HS, et al., Hepatitis B: Evolving Epidemiology and Implications for Control.  
Semin Liver Dis.1991; 11:84-92. 
 
4.  Alter MJ, et al. The Changing Epidemiology of Hepatitis B in the United States: Need for 
Alternative Vaccination Strategies.  JAMA 1990; 263:1218-22. 
 
5.  Krugman S, et al., Viral Hepatitis, Type B. Studies on Natural History and Prevention Re-
Examined. N Engl J Med 1979; 300:101-6. 
 
6.  Hoofnagle JH, et al., Serologic Diagnosis of Acute and Chronic Viral Hepatitis.  Semin Liver 
Dis 1991; 11:73-83 
 
7.  de Oliveira PR, et al., Hepatitis B Viral Markers in Banked Human Milk Before and after 
Holder Pasteurization.  J Clin Virol 2009; 45:281-4. 
 
8.  Hill JB, et al., Risk of Hepatitis B Transmission in Breast-Fed Infants of Chronic Hepatitis B 
Carriers.  Obstet Gynecol 2002; 99;1049-52. 
 
9.  Bloom BS, et al., A Reappraisal of Hepatitis B Virus Vaccination Strategies Using Cost 
Effectiveness Analysis.  Ann Intern Med 1993; 118:298-306. 
 
10. Centers for Disease Control and Prevention. A Comprehensive Immunization Strategy to 
Eliminate Transmission of Hepatitis B Virus Infection in the United States. 
Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: 
Immunization of Infants, Children, and Adolescents.  MMWR 2005; 54(RR16); 1-23. 
 
11. Centers for Disease Control and Prevention. A Comprehensive Immunization Strategy to 
Eliminate Transmission of Hepatitis B Virus Infection in the United States 
Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: 
Immunization of Adults. MMWR 2006; 55(RR16); 1-40. 
 
12. Department of Health and Human Services.  Combating the Silent Epidemic of Viral 
Hepatitis: Action Plan for Prevention Care and Treatment of Viral Hepatitis.  Available at 
http://www.hhs.gov/ash/initiatives/hepatitis/. 
 
  8 Contains Nonbinding Recommendations 
13. Koksal N, et al., Transient Hepatitis B Surface Antigenemia after Neonatal Hepatitis B 
Immunization. Acta Paediatr  1996; 85:1501-2. 
 
14. Kloster B, et al., Hepatitis B Surface Antigenemia in Blood Donors Following Vaccination.  
Transfusion 1995; 35:475-7. 
 
15. Lunn ER, et al., Prolonged Hepatitis B Surface Antigenemia after Vaccination.  Pediatrics 
2000; 105:E81. 
 
16. FDA Memorandum to All Registered Blood Establishments: Recommendations Concerning 
Testing for Antibody to Hepatitis B Core Antigen (Anti-HBc), September 10, 1991. 
http://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/Licens
edProductsBLAs/BloodDonorScreening/InfectiousDisease/ucm077899.htm. 
 
17. Guidance for Industry: Requalification Method for Reentry of Blood Donors Deferred 
Because of Reactive Test Results for Antibody to Hepatitis B Core Antigen (anti-HBc), May 
2010. 
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