Serological evidence of hepatitis B virus exposure and vaccination coverage trends in health sciences students in Albania

Abstract

BACKGROUND

Hepatitis B virus remains an important occupational risk for healthcare trainees. Objective serology can verify protection and inform pre-placement clearance policies.

AIM

To assess hepatitis B vaccination status, occupational exposure, and serological protection among health sciences students in Albania.

METHODS

Cross-sectional study (April-June 2024) at the University of Vlore. Students completed a structured questionnaire (n = 152); a consenting subset provided blood samples for hepatitis B surface antigen and anti-hepatitis B surface antibody (HBs) testing (n = 134). Group comparisons used χ²/Fisher’s exact tests and multivariable logistic regression for seroprotection (anti-HBs ≥ 10 IU/L).

RESULTS

All tested participants were hepatitis B surface antigen negative (n = 134). Overall, 86.6% had protective anti-HBs (≥ 10 IU/L), including 76.2% with titers > 100 IU/L; 13.4% had anti-HBs < 10 IU/L. Needlestick/sharps injuries were reported during training, supporting the need for standardized clearance and reporting pathways.

CONCLUSION

Most students had serological protection, but a meaningful minority lacked protective titers. Universities and training sites should implement pre-placement HB clearance with documented vaccination, mandatory anti-HBs testing, and structured catch-up/booster pathways.

Key Words: Hepatitis B; Healthcare students; Vaccination coverage; Anti-hepatitis B surface antibody; Hepatitis B surface antigen; Needlestick injury; Albania; Seroprotection; Post-vaccination serologic testing

Core Tip: In Albanian health sciences students, objective serology showed high overall hepatitis B seroprotection, but 1 in 7 lacked protective anti-hepatitis B surface antibody titers and reported occupational exposures. Pre-placement clearance should combine documented vaccination, mandatory anti-hepatitis B surface antibody testing, and structured catch-up/booster pathways with non-punitive exposure reporting.

INTRODUCTION

Hepatitis B virus (HBV) is a highly infectious, vaccine-preventable bloodborne pathogen and a well-established oncogenic agent. Acute infection can progress to chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC), making HBV a persistent public health problem and a major occupational safety concern in clinical environments where exposure to blood and body fluids is routine. Despite decades of vaccine availability, HBV continues to impose a substantial global burden. The World Health Organization estimates that in 2022 approximately 254 million people were living with chronic HBV infection, with about 1.2 million new infections and about 820000 deaths annually due to HBV-related cirrhosis and HCC[1]. These figures reflect both historical transmission and ongoing gaps in prevention, including incomplete vaccination in certain adult cohorts and insufficient verification of immunity among individuals entering high-risk settings[2].

HBV is particularly relevant for healthcare personnel and healthcare trainees because transmission can occur through percutaneous injuries (e.g., needlestick and sharps injuries), mucosal exposure, or direct contact with contaminated blood/body fluids. The virus is environmentally resilient and can remain infectious on surfaces for at least seven days; it is also substantially more transmissible than human immunodeficiency virus in occupational settings[3]. In this context, vaccination is the cornerstone of prevention, but documentation alone is not always sufficient. Post-vaccination serological testing (PVST), typically based on anti-hepatitis B surface antibody (HBs) titers, is operationally important to confirm protective immunity (anti-HBs ≥ 10 IU/L), identify low or waning antibody levels, and detect true non-responders who may remain susceptible and require specific post-exposure management strategies[4]. Without PVST, institutions cannot reliably distinguish students who are protected from those who are incompletely protected or unprotected, particularly when vaccination records are missing or uncertain.

In Albania, hepatitis B vaccination has been included in the national immunization schedule since the mid-1990s, with a birth dose followed by doses in infancy. This policy likely strengthened population-level protection in cohorts vaccinated from birth, but current university student populations include individuals born around transitional periods and those with incomplete documentation, creating uncertainty regarding vaccination history and the true level of serological protection. At the University of Vlore “Ismail Qemali”, nursing and midwifery students undertake clinical placements in settings where blood exposure and sharps use are common (e.g., phlebotomy, injections, wound care, and obstetric/gynecologic assistance). In the present cohort, needlestick injuries were frequently reported (64.5%), and underreporting was substantial - patterns consistent with evidence from comparable European student populations[5,6]. These observations underscore a practical need for standardized, pre-placement clearance pathways that integrate verified vaccination status, serological confirmation of immunity, and clearly defined post-exposure procedures.

This study was designed to quantify HBV serological status and vaccination coverage among nursing and midwifery students at the University of Vlore, with emphasis on the distribution of anti-HBs titers (including protective and strong protection thresholds) and screening for current infection using hepatitis B surface antigen (HBsAg). The analysis also examines how vaccination history and exposure-related behaviors relate to confirmed serological protection, to inform feasible institutional policies for occupational health clearance and prevention. Overall study enrollment comprised 152 students; 134 had complete serological test results available for analysis, and denominators are reported accordingly across outcomes.

MATERIALS AND METHODS

Study design and setting

A cross-sectional study was conducted between April and June 2024 at the University of Vlore “Ismail Qemali”, Faculty of Health (Albania). The study evaluated HBV prevention status in healthcare trainees using: (1) Objective serological markers of HBV infection and immunity (HBsAg and anti-HBs); and (2) Questionnaire-based information on vaccination history and occupational exposure during clinical training.

Study population, eligibility, and sampling

The target population included undergraduate students enrolled in General Nursing and Midwifery programs who were attending courses and/or clinical placements during the study period. Students were eligible if currently registered at the Faculty of Health and willing to participate. Participation was voluntary; students could complete the questionnaire without consenting to blood sampling.

A total of 152 students (n = 152) were recruited using systematic random sampling with probability proportional to size to ensure representation across the two programs. All participants completed the questionnaire. Serological testing required separate written consent; therefore, 134 students (n = 134) provided blood samples and had valid serological results. Accordingly, serology-based analyses (HBsAg and anti-HBs) used n = 134, while questionnaire-only analyses used n = 152.

Sample size rationale

The minimum required sample size for estimating a single proportion was calculated using: Z = 1.96 for 95% confidence, P = 9.5% based on available Albanian estimates of HBV infection, and d = 5% margin of error[7].

We recruited 152 students to allow for missing or incomplete questionnaires/serology results and to ensure adequate numbers in each study program, improving the precision of the estimates.

Questionnaire data (vaccination history and exposure)

Data were collected using a structured, self-administered questionnaire adapted from Abdela et al[8], in 2016 and tailored to the local academic and clinical-training context. For the present analysis, the questionnaire captured: (1) Sociodemographic/academic characteristics; (2) Hepatitis B vaccination history (self-reported and/or documented where available); and (3) Occupational exposure during training, including needlestick/sharps injuries and reporting behavior. Additional items assessed common HBV exposure risks (e.g., tattooing/piercing, dental/surgical procedures, blood transfusion history, unprotected sex, and injection drug use). HBV vaccination history was obtained in two ways: (1) Self-reported vaccination status from the questionnaire; and (2) Baseline vaccine doses verified through postnatal vaccination registries at Mother and Child Consultancy after birth.

Field procedures for questionnaire administration

Questionnaires were administered during scheduled class sessions to minimize non-response and standardize completion conditions. Students received a brief explanation of study aims, confidentiality, and voluntary participation. Completed questionnaires were collected immediately.

Measures: HBV knowledge score

HBV knowledge score. A total HBV knowledge score was created from 11 core knowledge items (Section B), coded 1 for correct and 0 for incorrect/“don’t know”. Scores were summed (range 0-11), with higher scores indicating better knowledge. All 11 items were complete in the serology analytic sample (n = 134). Internal consistency was Cronbach’s alpha = 0.82.

Serological testing (HBsAg and anti-HBs)

Specimen collection and processing: Trained laboratory personnel collected 5 mL of venous blood under aseptic conditions into plain vacutainer tubes. Samples were labeled using anonymized study codes and transported under cold-chain conditions to the laboratory. Serum was separated by centrifugation (approximately 3000 rpm for about 10 minutes). Sera were analyzed promptly when feasible; otherwise, samples were stored at 2-8 °C short-term or -20 °C if testing was delayed, following routine laboratory practice.

Assays and interpretation (HBsAg and anti-HBs). Serum samples were tested for HBsAg and anti-HBs using VIDAS^® automated immunoassay platform (bioMérieux, France) using the enzyme-linked fluorescent assay technique, according to the laboratory standard operating procedure. HBsAg results were reported as a cut-off index (COI) and interpreted as non-reactive (COI < 0.9), reactive (COI ≥ 1.0), and equivocal/borderline (COI 0.9-1.1); equivocal results were repeated and/or confirmed per standard operating procedure.

Anti-HBs concentrations were reported in IU/L (numerically equivalent to mIU/mL) and categorized as < 10 IU/L (not protected), 10-100 IU/L (protective/Low-moderate), and > 100 IU/L (strong response). For regression analyses, seroprotection was defined as anti-HBs ≥ 10 IU/L.

Data linkage and confidentiality

Serology results were linked to questionnaire data using anonymized codes only; no personal identifiers were stored in the analytic dataset. Electronic files were password-protected with restricted access.

Statistical analysis

The statistical methods of this study were reviewed by a biomedical statistician (insert name and affiliation). Descriptive statistics were used to summarize participant characteristics, vaccination history, exposure indicators, and serology outcomes. Seroprevalence and seroprotection estimates were reported with 95% confidence intervals (CIs), using appropriate denominators (n = 134 for serology outcomes). Group comparisons were performed using χ² or Fisher’s exact tests for categorical variables and t-tests or non-parametric alternatives for continuous variables, as appropriate. Multivariable logistic regression was used to estimate adjusted associations between vaccination/exposure-related factors and seroprotection (anti-HBs ≥ 10 IU/L). Statistical significance was set at P < 0.05.

Ethical considerations

This study was approved by the Medical Ethics Committee of University of Vlore Faculty of Health, approval No. 80/1. Written informed consent was obtained prior to questionnaire completion, and separate consent was obtained for venous blood sampling. Participation was voluntary and students could withdraw at any time without academic consequences.

RESULTS

Participant characteristics

A total of 152 students participated in the study (Table 1). Females represented 84.9% of the sample, reflecting the typical gender distribution in nursing and midwifery programs. The mean age was 23.8 years (SD 5.7), with a wide age range (19-51 years), indicating the presence of both traditional students and a non-negligible proportion of mature students. Most participants were aged 19-24 years (78.3%), while 12.5% were aged ≥ 30 years. In terms of academic pathway, Bachelor-level students comprised the majority (bachelor of nursing 46.7%; bachelor of midwifery 28.9%), whereas postgraduate students constituted 24.3% of the cohort (professional master’s 17.1%; scientific master’s 7.2%). Three-quarters of participants resided in urban areas (75.0%).

Table 1 Sociodemographic characteristics of study participants (n = 152).

Variable	n (%)
Gender
Female	129 (84.9)
Male	23 (15.1)
Age, years, mean ± SD	23.8 ± 5.7 (range: 19-51)
Age group
19-24	119 (78.3)
25-29	14 (9.2)
≥ 30	19 (12.5)
Study program
Bachelor of nursing	71 (46.7)
Bachelor of midwifery	44 (28.9)
Professional master’s	26 (17.1)
Scientific master’s	11 (7.2)
Residence
Rural	38 (25.0)
Urban	114 (75.0)

Practices

Preventive practices were mixed (Table 2). Although most students reported adherence to glove-changing between patients (86.8%), only 16.4% had ever undergone HBV screening. Self-reported vaccination coverage was 52.6%, leaving nearly half of participants without reported vaccination. Occupational exposure was common: 64.5% reported at least one needle-stick injury, and one-third of students (32.9%) reported not always reporting such injuries, highlighting a major gap in post-exposure management culture and institutional reporting pathways.

Table 2 Self-reported practices related to hepatitis B prevention and occupational exposure (n = 152), n (%).

Practice item	No	Yes	P value
Have you ever been screened for hepatitis B	127 (83.6)	25 (16.4)	< 0.001
Have you been vaccinated against hepatitis B	72 (47.4)	80 (52.6)	0.516
I always change gloves for each patient during blood taking	20 (13.2)	132 (86.8)	< 0.001
Have you ever had a needle-stick injury	54 (35.5)	98 (64.5)	< 0.001
I always report a needle-stick injury	50 (32.9)	102 (67.1)	< 0.001

Most participants (90.1%) reported having received three doses, consistent with Albania’s routine infant HBV immunization schedule (birth, 2 months, and 6 months) (Table 3). Nevertheless, 9.9% reported zero doses, suggesting missed infant immunization, incomplete documentation, or lack of subsequent catch-up vaccination. From an occupational health perspective, the absence of a systematic catch-up and verification mechanism before clinical placement remains a critical concern.

Table 3 Registry-verified baseline hepatitis B vaccine doses received (n = 152).

Number of doses	n (%)
0 doses	15 (9.9)
3 doses	137 (90.1)

Serological testing (HBsAg and anti-HBs)

Serological testing was performed to assess current infection (HBsAg) and protective immunity (anti-HBs). Because of incomplete availability of serum for all participants, serology-based analyses were conducted in the subgroup with complete serological data (n = 134), and denominators are reported explicitly for each analysis.

Findings are summarized

All participants had HBsAg values below the assay cut-off (COI < 0.9), indicating no evidence of active HBV infection in the tested subgroup. Anti-HBs concentrations showed substantial variability, with values ranging from 2 IU/L to 1000 IU/L, consistent with heterogeneity in vaccine response and/or waning antibody levels over time (Table 4).

Table 4 Descriptive statistics for hepatitis B surface antigen and anti-hepatitis B surface antibody levels among participants with serology (n = 134).

Marker	Mean	SD	Min	Median	Q3	Max
HBsAg (COI)	0.25	0.08	0.07	0.27	0.33	0.39
Anti-HBs (IU/L)	253.2	225.5	2.0	215.5	324.8	1000.0

HBsAg: Hepatitis B surface antigen; HBs: Hepatitis B surface antibody; COI: Cut-off index; Min: Minimum; Max: Maximum.

Overall, 86.6% of participants had protective anti-HBs levels (≥ 10 IU/L). Nevertheless, 13.4% had anti-HBs < 10 IU/L, indicating lack of serological protection and the need for revaccination assessment and/or booster strategies before clinical exposure. A large majority (76.1%) demonstrated strong antibody responses (> 100 IU/L), suggesting robust post-vaccination immunity in most students (Table 5).

Table 5 Distribution of participants by anti-hepatitis B surface antibody level category (n = 134).

Anti-HBs category (IU/L)	n
< 10	18
10-100	14
> 100	102
Total	134

HBs: Hepatitis B surface antibody.

Anti-HBs distributions did not differ significantly by gender, age group, program, or residence (all P > 0.05) (Table 6). Bachelor of midwifery students had the highest proportion with anti-HBs < 10 IU/L (24.1%), but differences across programs were not statistically significant in unadjusted comparisons. Notably, a small subgroup reporting zero vaccine doses still exhibited high anti-HBs levels, which may reflect undocumented vaccination, misclassification in self-report, or past exposure with immune response; this finding underscores the importance of verifying immunization records and using serology to guide occupational health decisions.

Table 6 Anti-hepatitis B surface antibody level categories by participant characteristics (n = 134), n (%).

Variable	< 10	10-100	> 100	P value
Gender				0.507
Female	16 (14.2)	13 (11.5)	84 (74.3)
Male	2 (9.5)	1 (4.8)	18 (85.7)
Age group				0.905
19-24	15 (14.3)	12 (11.4)	78 (74.3)
25-29	1 (8.3)	1 (8.3)	10 (83.3)
≥ 30	2 (11.8)	1 (5.9)	14 (82.4)
Study program				0.622
Bachelor of nursing	8 (11.3)	9 (12.7)	54 (76.1)
Bachelor of midwifery	7 (24.1)	2 (6.9)	20 (69.0)
Professional master’s	2 (8.7)	2 (8.7)	19 (82.6)
Scientific master’s	1 (9.1)	1 (9.1)	9 (81.8)
Residence				0.643
Rural	5 (15.6)	2 (6.2)	25 (78.1)
Urban	13 (12.7)	12 (11.8)	77 (75.5)
Reported baseline HBV doses				0.876
0 doses	2 (13.3)	1 (6.7)	12 (80.0)
3 doses	16 (13.4)	13 (10.9)	90 (75.6)

HBV: Hepatitis B virus.

In participants with serology (n = 134), there was a weak positive correlation between age and anti-HBs concentration (r = 0.167; 95%CI: -0.002 to 0.328; P = 0.053). Although the regression line suggested a slight upward trend, the association did not reach statistical significance, and antibody concentrations displayed wide dispersion across the age range.

Multivariable logistic regression: Predictors of protective immunity

A multivariable logistic regression model was fitted to identify independent predictors of protective immunity, defined as anti-HBs ≥ 10 IU/L (protective = 1; non-protective = 0). Predictors included program of study, age, gender, HBV vaccination history, consistent reporting of needle-stick injuries, and total HBV knowledge score (Table 7).

Table 7 Multivariable logistic regression predictors of protective immunity (anti-hepatitis B surface antibody ≥ 10 IU/L) (n = 134).

Predictor	B	SE	Z	P value	Adjusted OR	95%CI (lower)	95%CI (upper)
Knowledge score (per 1-point)	-0.218	0.134	-1.62	0.103	0.803	0.618	1.045
Age (per 1-year)	-0.144	0.074	-1.94	0.052	0.865	0.749	1.001
Not vaccinated (vs vaccinated)	-3.626	1.819	-1.99	0.046	0.026	0.001	0.942
Bachelor of midwifery (vs bachelor of nursing)	-1.963	0.539	-3.63	< 0.001	0.140	0.049	0.404
Professional master’s (vs bachelor of nursing)	-0.295	0.738	-0.39	0.689	0.744	0.175	3.155
Scientific master’s (vs bachelor of nursing)	0.540	1.161	0.47	0.641	1.717	0.178	16.63
Always report needlestick injury (yes vs no)	-0.603	0.546	-1.10	0.269	0.547	0.188	1.586
Male (vs female)	-0.197	0.677	-0.29	0.770	0.820	0.219	3.10

The intercept (constant) was omitted because it is included for model specification and is not intended for clinical interpretation. OR: Odds ratio; CI: Confidence interval.

In the adjusted model, two predictors were statistically significant. First, Bachelor of Midwifery students had substantially lower odds of protective immunity compared with Bachelor of Nursing students [adjusted odds ratio (OR) = 0.14; 95%CI: 0.049-0.404; P < 0.001]. Second, participants classified as not vaccinated had markedly lower odds of protective immunity than vaccinated participants (adjusted OR = 0.026; 95%CI: 0.001-0.942; P = 0.046), consistent with the biological expectation that vaccination increases serological protection. Age showed a borderline association (adjusted OR = 0.87 per year; P = 0.052), suggesting possible waning of antibodies with increasing age. Knowledge score, gender, and self-reported consistent reporting of needle-stick injuries were not independently associated with protective immunity (all P > 0.05).

DISCUSSION

This study provides a combined picture of HBV serological protection (anti-HBs), current infection screening (HBsAg), and vaccination coverage patterns among nursing and midwifery students at the University of Vlore. The main message is simple: Students generally understand how HBV spreads in clinical practice, but there are clear gaps in immunity verification, screening behavior, and post-exposure preparedness, which are the pieces that actually determine real-world protection in training environments.

Serological protection and vaccination coverage gaps

The serology results show that a meaningful subgroup of students either had non-protective anti-HBs titers (< 10 IU/L) or had not verified their immunity status, despite being in a high-risk setting. This matters because vaccine documentation alone does not reliably translate into confirmed protection - especially when records are incomplete, vaccination occurred many years earlier, or response status is unknown. The apparent discordance between self-reported HBV vaccination (52.6%) and serological protection (anti-HBs ≥ 10 IU/L, 86.6%) is best explained by the difference between self-report and registry-verified baseline vaccination history. In this cohort, baseline vaccine doses were verified through postnatal vaccination registries at Mother and Child Consultancy after birth, and documentation showed that the great majority had completed a three-dose series, whereas many participants did not recall or report their vaccination accurately. This is consistent with recall bias, loss of personal records, and misclassification in transitional cohorts. For this reason, occupational clearance should not rely on self-reported vaccination alone, and serology-based assessment remains the most reliable approach to confirm current protection and identify those needing follow-up (anti-HBs < 10 IU/L).

International occupational health guidance emphasizes PVST in blood-exposed groups specifically to identify those who are unprotected and to direct boosters/revaccination when needed[9,10]. In practical terms, the “coverage” problem here is not only whether the student reports vaccination, but whether baseline vaccination can be verified through registries and whether protection can be confirmed serologically before clinical placement.

Knowledge profile: Strong on transmission, weaker on HCC and post-exposure prophylaxis

The knowledge pattern in this cohort is typical: Students performed well on immediate, procedure-linked risks (blood contact, sharps exposure) but showed weaker understanding of HBV’s long-term outcomes (HCC) and post-exposure prophylaxis (PEP). Only about 40% correctly identified liver cancer as an HBV-related outcome despite HBV being a major carcinogenic infection globally[1]. Similar “near-term vs long-term” knowledge asymmetries have been reported in student populations, where infection-control facts are reinforced daily, while chronic sequelae and PEP decision-making are taught less consistently or less practically[11,12].

This gap is not academic. Poor PEP literacy delays reporting and clinical assessment after exposure, and weak understanding of chronic outcomes reduces perceived importance of immunity verification, particularly when students assume childhood vaccination equals lifelong protection without checking.

Occupational exposure and underreporting: A system problem, not a student “attitude” problem

The proportion reporting at least one needlestick injury (64.5%) indicates substantial occupational exposure during training. Underreporting - approximately one-third of exposures not formally reported - creates missed opportunities for timely source testing, risk stratification, and post-exposure management. Underreporting also undermines institutional surveillance, because exposure data are used to identify high-risk procedures, settings, and supervision gaps, and to evaluate whether safety interventions (training, PPE availability, sharps disposal systems) are actually reducing incidents over time. When exposures remain undocumented, both the student and the institution lose the ability to ensure appropriate follow-up, document outcomes, and implement targeted prevention at the level of the training environment. Although a formal reporting mechanism exists at the University/training sites, the observed underreporting suggests gaps in awareness, accessibility, or perceived consequences; therefore, reporting instructions and contact points should be standardized and clearly communicated before each clinical placement. This aligns with broader evidence that underreporting among trainees is common and is driven less by “bad behavior” and more by unclear reporting pathways, fear of consequences, and normalization of minor injuries[9-11]. The implication is straightforward: If reporting is optional, complicated, or perceived as punitive, underreporting will persist.

Predictors of protective immunity: Vaccination history and program differences

In multivariable logistic regression, vaccination history emerged as the key independent predictor of serological protection, which is consistent with decades of vaccine effectiveness and occupational health evidence[13]. The observed program-level differences - midwifery students showing lower odds of protection compared with nursing students - suggest that protection is shaped by institutional and organizational factors (e.g., enforcement of pre-placement requirements, access to vaccination services, follow-up) rather than knowledge alone. This interpretation is strengthened by the finding that knowledge scores did not remain independently associated with protection after adjustment, reinforcing that “knowing” does not guarantee vaccination completion, PVST, or booster uptake when systems do not make those steps easy and mandatory[13,14]. A borderline negative association with age is plausible biologically and programmatically, because anti-HBs titers may decline over time, particularly when primary vaccination occurred in infancy. Importantly, declining or even undetectable anti-HBs does not necessarily indicate loss of protection, as immune memory and anamnestic responses can persist despite low circulating antibody. However, in occupational health practice - especially for blood-exposed healthcare trainees - anti-HBs measurement remains essential for clearance decisions and risk management, because it distinguishes individuals with documented seroprotection from those who require booster evaluation or revaccination and helps define post-exposure pathways for potential non-responders[15-18]. For clinical training safety, the operational issue remains the same: Titers should be measured, not assumed.

Immunity-behavior profiles: Why one-size-fits-all policies fail

The cluster analysis adds a useful implementation insight: Students can be immune but non-compliant (complacency risk), or non-immune despite good knowledge (systems gap), alongside the expected “immune and compliant” and “non-immune and low knowledge” profiles. This segmentation matters because it points to different levers: (1) “Non-immune and low knowledge” needs basic education plus fast-track vaccination; (2) “Non-immune and high knowledge” needs access and administrative clearance pathways, not more lectures; and (3) “Immune and non-compliant” needs reinforcement of standard precautions and mandatory incident reporting, because HBV immunity does not protect against other bloodborne risks and does not justify unsafe practice[19,20].

The take-home point is that institutional design (clearance requirements, PVST, easy vaccine access, non-punitive reporting) is the main determinant of protection, and behavioral training works best when it is embedded in those systems[21-23].

Practical implications for universities and training sites

Based on these findings, the highest-yield intervention is a standardized pre-placement HBV clearance pathway: (1) Verified vaccination status (complete series or documented catch-up); (2) Mandatory PVST (anti-HBs) before clinical rotations; (3) Booster/revaccination algorithm for low or absent titers; and (4) A simple, non-punitive exposure reporting pathway with immediate access to risk assessment and PEP protocols.

This shifts HBV prevention from “student responsibility” to occupational safety governance, which is how it is handled effectively in higher-performing systems[24].

Strengths and limitations

A key strength is the integration of objective serology with vaccination and exposure-related information, enabling a more accurate assessment of protection than self-report alone. Limitations include the cross-sectional design (no causal inference), potential bias in self-reported vaccination/exposure reporting, and the single-institution setting which may limit generalizability to other Albanian universities or health programs. In addition, serology was available for a subset (n = 134), and denominators must be interpreted accordingly.

CONCLUSION

Most healthcare students in this cohort demonstrated serological protection against HBV, and no active infection (HBsAg positivity) was detected among those tested. However, a meaningful minority (13.4%) lacked protective anti-HBs titers, and occupational exposures - particularly needlestick injuries - were common. These findings support implementing standardized, pre-placement clearance policies in Albanian health-sciences programs, including documented vaccination status, mandatory PVST (anti-HBs), structured catch-up/booster vaccination for non-protected students, and clear, non-punitive reporting and post-exposure management pathways within clinical training sites.

ACKNOWLEDGEMENTS

Gratitude to the students who were available to carry out this study and agreed to be part of it by giving consent for blood tests to be performed.