|
|
|
|
|
| What are the signs and symptoms
of hepatitis B? |
 |
| About 7 out of 10 adults with
acute hepatitis B have signs or symptoms when infected
with HBV. Children under age 5 years who become infected
rarely show any symptoms. Signs and symptoms of hepatitis
B might include nausea, lack of appetite, tiredness, muscle,
joint, or stomach pain, fever, diarrhea or vomiting, headache,
dark urine, light-colored stools, and yellowing of the
skin and whites of the eyes (jaundice). People who have
such signs or symptoms generally feel quite ill and might
need to be hospitalized. The case fatality rate among
persons with reported cases of acute hepatitis B is
approximately 1%, with the highest rates occurring in adults
who are over 60 years of age. |
|
| How long does it take to
show signs of illness after a person becomes infected
with hepatitis B virus (HBV)? |
|
| The incubation period ranges
from 45 to 160 days (average 120.) |
|
| Can HBV be transmitted
in daycare via saliva, e.g., drooling infants? |
|
| Though HBV has
been found in saliva, there are no data to suggest that saliva
alone transmits HBV infection. There have been reports of HBV
transmission when an HBV-infected person bites another person.
In these reports, bloody saliva was usually present in the
infected person’s mouth and the blood was more likely the
vehicle of transmission. HBV is not spread by kissing,
hugging, sneezing,coughing, food or water, sharing eating
utensils or drinking glasses, or casual contact. |
|
| Can HBV
be transmitted by sharing cups or straws? |
|
| There are no data to suggest
that sharing drinking cups, straws, or other eating utensils,
have been associated with HBV transmission. |
|
| More of my patients
are getting tattoos and body piercings. Should they be
concerned about contracting a bloodborne infection like
HBV? |
|
| Yes. Tattooing and body piercing
have the potential to transmit bloodborne infections, including
HBV, hepatitis C virus (HCV), and human immunodeficiency
virus (HIV), if the person doing the tattoos or body piercing
does not use good infection control practices.
CDC recommends that instruments
intended to penetrate the skin be used once, then disposed
of or thoroughly cleaned and sterilized between clients.
Personal service workers who do tattooing or body piercing
should be educated about the transmission of bloodborne
pathogens and what precautions are needed to prevent transmission.
Persons considering getting
a tattoo or having a body part pierced should ask staff
at the establishment what procedures they use to prevent
the spread of bloodborne infections. They also might call
the local health department to find out what sterilization
procedures are required by law or ordinance for tattooing
and body piercing establishments.
IAC
has created a Web site with links to relevant articles
from medical journals and publications from national sources
such as CDC, HCV Advocate, the Alliance of Professional
Tattooists, and the Association of Professional Piercers.
Feel free to refer patients who are considering one or
both of these forms of body art to www.immunize.org/tattoos. |
|
| What is the risk for
transmitting HBV by oral sex? |
|
| There are no specific data
on transmission of bloodborne viruses through oral-genital
sex. Saliva has not been associated with HBV transmission
unless biting has taken place. HBV is not spread by kissing,
hugging, sneezing, coughing, food or water, sharing eating
utensils or drinking glasses, or casual contact. |
|
| Can "French" kissing transmit
HBV? |
|
| While HBV has been found in
saliva, there are no data to suggest that kissing transmits
HBV; however, there have not been studies to specifically
look at "French" kissing. |
|
| I tested positive for
chronic HBV infection about 5 months ago. I know there
is a vaccine to prevent transmission, however, I would
like to know how long my sex partner (I don't have one
now) should wait after taking this vaccine, before having
sex with me without any risk of transmission. |
|
| You should use
condoms (the efficacy of latex condoms in preventing infection
with HBV is unknown, but their proper use might reduce
transmission) until a postvaccination blood test (anti-HBs)
shows that your sex partner is protected from HBV infection.
For example, your sexual partner should have the 3-dose
series of hepatitis B vaccine and postvaccination testing
1-2 months after the last dose of vaccine. If your sexual
partner's test shows adequate anti-HBs (at least 10 mIU/mL),
then he/she should be protected against HBV infection. |
|
| If a patient is diagnosed
with acute hepatitis B and then resolves the infection,
can the patient ever get hepatitis B again? |
|
| Generally speaking, no. It
is possible, however, for a person to have two different
HBV infections, the second due to an HBV variant or a different
HBV subtype. |
|
| How stable is HBV in the
environment and what types of equipment cleaners are
viracidal against HBV? |
|
| Any high level
disinfectant that is tuberculocidal will kill HBV. It is important to note that
HBV is quite stable in the environment and remains viable
for 7 or more days on environmental surfaces at room temperature.
The virus is still capable of transmitting HBV despite
the absence of visible blood. |
| |
|
|
|
|
| What are
the various serologic tests for hepatitis B? |
|
| Table
1: Hepatitis B laboratory nomenclature |
| HBsAg: |
Hepatitis
B surface antigen is a marker of infectivity.
Its presence indicates either acute or chronic
HBV infection. |
| anti-HBs: |
Antibody
to hepatitis B surface antigen is a marker
of immunity. Its presence indicates an immune response
to HBV infection, an immune response to vaccination,
or the presence of passively acquired antibody.
(It is also known as HBsAb, but this
abbreviation is best avoided since it is often
confused with abbreviations such as HBsAg.) |
| anti-HBc
(total): |
Antibody
to hepatitis B core antigen is a nonspecific
marker of acute, chronic, or resolved HBV infection.
It is not a marker of vaccine-induced immunity.
It may be used in prevaccination testing to determine
previous exposure to HBV infection. (It is also
known as HBcAb, but this abbreviation
is best avoided since it is often confused with
other abbreviations.) |
| IgM
anti-HBc: |
IgM antibody
subclass of anti-HBc. Positivity indicates
recent infection with HBV (<6 mos). Its
presence indicates acute infection. |
| HBeAg: |
Hepatitis
B "e" antigen is a marker of a high
degree of HBV infectivity, and it correlates with
a high level of HBV replication. It is primarily
used to help determine the clinical management
of patients with chronic HBV infection. |
| Anti-HBe: |
Antibody
to hepatitis B "e" antigen may be
present in an infected or immune person. In persons
with chronic HBV infection, its presence suggests
a low viral titer and a low degree of infectivity. |
| HBV-DNA: |
HBV Deoxyribonucleic
acid is a marker of viral replication. It correlates
well with infectivity. It is used to assess and
monitor the treatment of patients with chronic
HBV infection. |
|
|
| How do I
interpret some of the common hepatitis B panel results? |
|
|
Table 2 |
| Tests |
Results |
Interpretation |
Vaccinate? |
HBsAg
anti-HBc
anti-HBs |
negative
negative
negative |
susceptible |
vaccinate
if indicated |
HBsAg
anti-HBc
anti-HBs |
negative
negative
positive with >10mIU/mL* |
immune
due to vaccination |
no
vaccination necessary |
HBsAg
anti-HBc
anti-HBs |
negative
positive
positive |
immune
due to natural infection |
no
vaccination necessary |
HBsAg
anti-HBc
IgM anti-HBc
anti-HBs |
positive
positive
positive
negative |
acutely
infected |
no
vaccination necessary |
HBsAg
anti-HBc
IgM anti-HBc
anti-HBs |
positive
positive
negative
negative |
chronically
infected |
no
vaccination necessary (may need treatment) |
HBsAg
anti-HBc
anti-HBs |
negative
positive
negative |
four
interpretations possible† |
use
clinical judgment |
| * |
Postvaccination testing, when it is recommended,
should be performed 1-2 months after the last dose of
vaccine. Infants born to HBsAg-positive mothers should
be tested for HBsAg and anti-HBs after completion of
at least 3 doses of a licensed hepatitis B vaccination
series, at age 9-18 months (generally at the next well
child visit). |
| †1. |
May be
recovering from acute HBV infection |
| 2. |
May be
distantly immune, but the test may not be sensitive
enough to detect a very low level of anti-HBs in
serum |
| 3. |
May be
susceptible with a false positive anti-HBc |
| 4. |
May be
chronically infected and have an undetectable level
of HBsAg present in the serum
|
|
|
| My daughter was immunized
against hepatitis B about 4 years ago. She was recently
found "hepatitis B positive" by her gynecologist. Is
this possible? Could it be a false positive? |
|
| It is possible, but unlikely.
The HBsAg test has high sensitivity and specificity and
is quite trustworthy. She might have already been HBsAg
positive when she was vaccinated; therefore, the vaccine
would not have been effective. You should be assured that
the positive test was actually HBsAg and not another hepatitis
B test, such as anti-HBs (sometimes confusingly referred
to as HBsAB) or anti-HBc. A positive anti-HBs test is expected
after vaccination with hepatitis B vaccine, but not a positive
anti-HBc or HBsAg. If you are certain after careful checking
that the test and reported result are correct, you should
then make sure the laboratory that did the test repeated
the test in duplicate and then did neutralization. If your
daughter is ultimately determined to be truly HBsAg positive,
she should be referred to a liver disease specialist for
counseling and medical evaluation. |
|
| I work in a dialysis
unit. Our lab reports anti-HBs results as adequate or
inadequate, rather than providing a quantitative result.
Is this acceptable? |
|
| Reporting of adequate and inadequate
is acceptable only if your lab is using mIUs as the measurement
for anti-HBs and the cutoff is below 10 for reporting inadequate
anti-HBs and 10 or above for reporting adequate anti-HBs.
You should check with your lab to be certain this is being
done. |
| |
|
|
|
|
| Where can I locate CDC's
recommendations for hepatitis B vaccination? |
|
|
To obtain "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,
December 23, 2005, Vol. 54(RR-16):1-39 go to
www.cdc.gov/mmwr/PDF/rr/rr5416.pdf.
For the adult recommendations titled
"A Comprehensive Immunization Strategy to Eliminate Transmission
of Hepatitis B Virus Infection in the United States. Part II:
Immunization of Adults," MMWR, December 8, 2006;55(RR-16):1-25 go
to
www.cdc.gov/mmwr/PDF/rr/rr5516.pdf. |
|
I understand there is a
now a shortage of HepB vaccine for children and possibly for
adults. Could you please tell me about it and what we should
do to cut back on using it? |
|
| The supply of Merck's
hepatitis B vaccines (pediatric, adult, and dialysis
formulations) is limited at this time, but recommendations for
its use are unchanged. For detailed information about HepB
shortages, go to CDC's website at
www.cdc.gov/vaccines/vac-gen/shortages. |
|
How much protection
is provided for babies, teens, and adults after each
dose of hepatitis B vaccine? |
|
| Among a sample of
vaccinated persons, 56%-62% were positive for neutralizing
antibody 14 days after the first dose, and 94%-100% were
positive at one month. Other studies show that after one dose
of vaccine, protection ranges from 5%-35%; after two doses,
50%-90%; after three doses 85%-100%. The estimates vary a
great deal from study to study, even using the same vaccine
and the same dosage. However, considering the fact that the
vaccination series alone works very well after exposure, and
that the exposed person does not get even a second dose until
at least 1 MONTH after the exposure, most would agree that
there is good (but probably not long lasting) protection even
after a single dose for most persons. |
|
| For how long is hepatitis
B vaccine protective? |
|
| Studies indicate that
immunologic memory remains intact for at least 23 years
and confers protection against clinical illness and chronic HBV infection, even though anti-HBs levels might become
low or decline below detectable levels. |
|
| Is hepatitis B vaccine safe? |
|
| Yes. Hepatitis B vaccines have
been demonstrated to be safe when administered to infants,
children, adolescents, and adults. Since 1982, an estimated
70 million adolescents and adults and 50 million infants
and children in the United States have received at least
one dose of hepatitis B vaccine; a billion doses of hepatitis
B vaccine have been given worldwide. Vaccination causes
a sore arm occasionally, but serious reactions are very
rare. |
|
| Where can I find a
CDC document that states that hepatitis B vaccine doesn't
have to be restarted if the series is interrupted? |
|
| A discussion of interrupted
hepatitis B vaccination schedules can be found in the
recommendations of the ACIP Part 1: Immunization of Infants,
Children, and Adolescents published December 23, 2005. Go to
www.cdc.gov/mmwr/PDF/rr/rr5416.pdf. It is on page 8. The
document states: |
| |
| • |
|
When the
hepatitis B vaccine schedule is interrupted, the vaccine
series does not need to be restarted. |
| • |
|
If the
series is interrupted after the first dose, the second
dose should be given as soon as possible, and the second
and third doses should be separated by an interval of at
least 8 weeks. |
| • |
|
If only the third dose
is delayed, it should be administered as soon as
possible, after age 24 weeks (164 days). |
| • |
|
It is not necessary to
restart the vaccine series for infants switched from one
vaccine brand to another, including combination
vaccines. |
|
|
| Who should not receive
the vaccine? |
|
A serious allergic reaction
to a prior dose of hepatitis B vaccine or a vaccine component
is a contraindication to further doses of hepatitis B vaccine.
The recombinant vaccines that are licensed for use in the
United States are synthesized by Saccharomyces cerevisiae
(common baker's yeast), into which a plasmid containing
the gene for HBsAg has been inserted. Purified HBsAg is
obtained by lysing the yeast cells and separating HBsAg
from the yeast components by biochemical and biophysical
techniques. Persons allergic to yeast should not be vaccinated
with vaccines containing yeast.
|
Persons with a history of serious
adverse events, including anaphylaxis, after receipt of
hepatitis B vaccine should not receive additional doses.
As with other vaccines, vaccination of persons with moderate
or severe acute illness, with or without fever, should
be deferred until the illness improves. Vaccination is
not contraindicated in persons with a history of multiple
sclerosis, Guillain-Barrè syndrome, or autoimmune
diseases such as systemic lupus erythematosis or rheumatoid arthritis. |
|
| If you want to test
and vaccinate your patient for hepatitis B on the same
day, does it matter if you test or vaccinate first? |
|
| Yes. You should draw the blood
first and then administer the first dose of vaccine, as
transient HBsAg-positivity has been found to occur after
a dose of hepatitis B vaccine. |
|
| How long should a person
wait to donate blood after a dose of hepatitis B vaccine? |
|
| It is advisable to wait one
month. Studies published in the last several years have
found that transient HBsAg positivity (lasting less than
21 days) can be detected in certain persons after vaccination. |
| |
|
|
|
|
|
Pregnancy, perinatal, and infant hepatitis B issues |
Back to top |
|
|
|
| Where can I obtain
a copy of the most recent recommendation of the Advisory
Committee on Immunization Practices (ACIP) for the
prevention of perinatal transmission of HBV infection? |
|
| You can access the
official document
and appendices at:
www.cdc.gov/mmwr/PDF/rr/rr5416.pdf. |
|
| What blood test should be used to screen a pregnant woman to prevent perinatal
hepatitis B virus (HBV) infection? |
|
| Screening should be done with
the hepatitis B surface antigen (HBsAg) test only. This
blood test will tell whether a woman has current HBV infection
that can be transmitted to her infant. Ordering other blood
tests such as total antibody to hepatitis B core antigen
(total anti-HBc) and/or antibody to HBsAg (anti-HBs) are
not useful when screening to prevent perinatal HBV infections
and should not be included in screening pregnant women
for perinatal HBV infection. Total anti-HBc will be positive
in all HBsAg-positive persons and anti-HBs is rarely positive
in an HBsAg-positive person. Women who are found to be
HBsAg positive should then be referred for counseling and
medical evaluation that will include further testing. If
there is reason to suspect recently acquired HBV infection
in a pregnant woman, IgM class anti-HBc (IgM anti-HBc)
could be done to differentiate recently acquired HBV infection
from chronic HBV infection. IgM anti-HBc is the blood test
that is positive in recently acquired HBV infection. |
|
| Our laboratory screens
pregnant women with a hepatitis B panel. Is this correct? |
|
| No. A routine
hepatitis B panel for screening pregnant women is not advised,
nor is it necessary to determine current infection in a
pregnant woman. This practice has led to a number of women
being incorrectly labeled as HBsAg positive due to misinterpretation
of the results on the lab report. In reporting results,
some labs use the nomenclature "HBsAb" rather than the
more commonly used term "anti-HBs" to designate antibody
to HBsAg. Because the term "HBsAb" is only one character
different from "HBsAg," the lab report is subject to misinterpretation
and a number of "immune" women are incorrectly labeled
as "HBsAg positive". Their infants are given unnecessary
postexposure treatment with hepatitis B immune globulin
(HBIG) and the women experience unnecessary stress. |
|
| Do women who have been
vaccinated previously against HBV infection still need
to be screened during pregnancy? |
|
| Yes. Women who have received
hepatitis B vaccine should still be screened for HBsAg
early with each pregnancy. Just because
a woman has been vaccinated does not mean she is HBsAg
negative. Since postvaccination testing is not performed
for most vaccinated persons, she could have been vaccinated
even though she was already HBsAg positive. |
|
| Is it safe to give
hepatitis B vaccine to a pregnant woman? |
|
| Yes. Limited data indicate
no apparent risk for adverse events to developing fetuses.
Current vaccines contain noninfectious HBsAg and should
cause no risk to the fetus. If the mother is being vaccinated
because she is at risk for HBV infection (e.g., a healthcare
worker [HCW], a person with an STD, an IDU, multiple sex
partners), vaccination should be initiated as soon as her
risk factor is identified during the pregnancy. In contrast,
HBV infection affecting a pregnant woman might result in
severe disease for the mother and chronic infection for
the newborn. |
|
| I've identified a patient
in my OB practice who is HBsAg positive. Should she
be evaluated for liver disease during her pregnancy,
or should the evaluation wait until the postpartum period?
What should I recommend for her husband and her children.
How urgent is the time frame? |
|
| The earlier the evaluation
is done, the better. Consultation or referral with a liver
disease specialist (i.e., hepatologist, gastroenterologist,
infectious disease) should be done. The consulting/referral
physician should be completely aware of the patient's obstetrical
status. In addition, the patient's sex partner and children
or other household contacts should be tested for HBV infection
(total antiHBc and HBsAg) as soon as possible. If any are
susceptible to HBV infection (anti-HBc and HBsAg negative),
they should be vaccinated; if any are HBsAg positive, they
should be referred to or have consultation with a liver
disease specialist. |
|
| I understand there is an
excellent rapid test for HBsAg available for use in hospitals
or clinics. Could you comment on this? |
|
There are EIA-licensed
HBsAg assays that do have a rapid turn-around, but no rapid
assays as such; however, if you are unable to convince your
lab to use such rapid turn-around assays or if you cannot
switch labs to do so, you should do the following:
|
|
| • |
|
Order an
HBsAg assay stat. Verify when the test result will be
available and that it will be reported to the newborn
nursery ASAP. If the nursery doesn’t receive the report
at the expected time, call the lab for the result. |
| • |
|
Follow the
perinatal recommendations based on a mother with unknown
HBsAg status. Make sure you give the first dose of
single-antigen hepatitis B vaccine to infants of mothers
of unknown status within 12 hours of birth. For preterm
infants weighing less than 2 kg, give HBIG plus
hepatitis B vaccine within 12 hours of birth. Don’t wait
for the HBsAg test result before proceeding with
hepatitis B vaccination since ALL newborns are
recommended to receive hepatitis B vaccine at birth. |
| • |
|
If you get a positive
maternal HBsAg test result from the laboratory, give the
infant HBIG as soon as possible (no later than age 7
days) and complete the vaccine series according to the
schedule for infants born to HBsAg-positive mothers. If
the mother’s HBsAg test result is negative, follow the
routine vaccination recommendations for subsequent
doses. |
| • |
|
Communicate the infant’s
vaccination record (and HBIG record, if any) and the
mother’s HBsAg status to both the infant’s and mother’s
healthcare professionals. Follow-up case management is
critical for an infant whose mother’s HBsAg test result
was unknown or positive. |
| • |
|
Contact the perinatal
hepatitis B program at your local or state health
department immediately when your hospital identifies an
HBsAg-positive mother or when an infant is born to an
HBsAg-positive mother or a mother whose status is
unknown at the time. |
|
|
| What should delivery hospitals
do to prevent perinatal HBV transmission? |
|
| The most important
thing you can do is to ensure that all newborns receive the
needed protection of hepatitis B vaccine and to make sure your
hospital has policies and procedures in alignment with the
recommendations of CDC, AAP, and AAFP, which include
establishing standing orders for administration of hepatitis B
vaccine as part of routine medical care of all medically
stable infants weighing 2 kg (4.4 lb) or more. By putting this
policy into place, you are ensuring that every newborn will
receive the birth dose prior to hospital discharge (unless an
order is written in the infant’s chart by the healthcare
provider to NOT give it). According to the official
recommendations, an order to delay the birth dose until after
hospital discharge may be done, on a case-by-case basis, and
only in rare circumstances. Guidelines for implementing birth
dose policies are found in the official CDC recommendations on
hepatitis B prevention in children available at
www.cdc.gov/mmwr/pdf/rr/rr5416.pdf. You can also use the labor and delivery and
nursery guidelines from the Immunization Action Coalition (IAC)
available at
www.immunize.org/catg.d/p2130.pdf. |
|
| Delivery hospitals
should enroll in the federally funded Vaccines for Children (VFC)
program to obtain free hepatitis B vaccine for administration
of the birth dose to newborns that are eligible (i.e.,
Medicaid eligible, American Indian or Alaska Native,
underinsured, or uninsured). The VFC information is available
at:
www.cdc.gov/vaccines/programs/vfc/default.htm. |
|
| Our hospital is dragging
its feet on reinstitution of a policy for the hepatitis
B vaccine birth dose. How can I help convince them that
this is the standard of care? |
|
| Administration of a birth dose
of hepatitis B vaccine is required for effective postexposure
immunoprophylaxis to prevent perinatal HBV infection. Although
infants who require postexposure immunoprophylaxis should
be identified by maternal HBsAg testing, administering
a birth dose to infants, even without HBIG, serves as a "safety
net" to prevent perinatal infection among infants born
to HBsAg-positive mothers who are not identified, because
of errors in maternal HBsAg testing or failure in reporting of
test results. |
|
| The birth dose provides early
protection to infants at risk for infection after the perinatal
period. Although infections in young children represented
less than 10% of all HBV infections before implementation
of routine childhood hepatitis B vaccination, childhood
infections resulted in an estimated 30%-40% of the chronic
HBV infections among persons who acquired their infections
in the United States. Many of these chronic infections
would not have been prevented by a selective program of
identification and immunization of only infants born to
HBsAg-positive mothers. |
|
| CDC recommends that all newborns
be vaccinated in the hospital prior to hospital discharge.
AAP and AAFP have also endorsed these recommendations.
CDC recommends the following with regard to administering
the birth dose: |
|
| • |
|
All delivery
hospitals should implement standing orders for administration
of hepatitis B vaccine as part of routine medical
care of all medically stable infants weighing 2 kg
(4.4 lb) or more at birth. |
| • |
|
All medically stable
infants weighing 2 kg or more at birth and born to
HBsAg-negative mothers should receive the first dose
of vaccine (single-antigen only) before hospital
discharge. |
| • |
|
On a case-by-case
basis and only in rare circumstances, the first dose
may be delayed until after hospital discharge for
an infant who weighs 2 kg or more and whose mother
is HBsAg negative. In this case, a physician’s order
not to give the birth dose must be written, and a
copy of the original HBsAg-negative laboratory report
during this pregnancy should be placed in the infant’s
medical record. The official CDC recommendations
for hepatitis B vaccination of children are available
at
www.cdc.gov/mmwr/pdf/rr/rr5416.pdf. |
|
|
| Administration of a birth dose
has been associated with higher rates of on-time completion
of the hepatitis B vaccine series. In certain populations,
the birth dose has been associated with improved completion
rates for all other infant vaccines. |
|
| For more information, go to www.immunize.org/birthdose. |
|
| If a mother's HBsAg
test result is not available at the time of birth, how
should the infant be managed? |
|
| • |
|
Women admitted
for delivery without documentation of HBsAg test
results should have blood drawn and tested as soon
as possible after admission. |
| • |
|
While test results are
pending, all infants born to women without documentation
of HBsAg test results should receive the first dose
of single-antigen hepatitis B vaccine (without HBIG)
by 12 hours of birth. |
| |
|
| • |
|
If
the mother is determined to be HBsAg positive,
her infant should receive HBIG as soon as possible
but no later than age 7 days, and the vaccine
series should be completed according to a recommended
schedule for infants born to HBsAg-positive
mothers. |
| • |
|
If
the mother is determined to be HBsAg negative,
the vaccine series should be completed according
to a recommended schedule for infants born
to HBsAg-negative mothers. |
| • |
|
If the mother has
never been tested to determine her HBsAg status
and testing is not available (e.g., in remote
locations), the vaccine series should be completed
according to a recommended schedule for infants
born to HBsAg-positive mothers. Administration
of HBIG is not necessary for these infants. |
|
| • |
|
Because of
the potentially decreased immunogenicity of vaccine
in preterm infants weighing less than 2kg, these
infants should receive both single-antigen hepatitis
B vaccine and HBIG (0.5 mL) if the mother's HBsAg
status cannot be determined by 12 hours of birth.
The birth dose of vaccine should not be counted as
part of the three doses required to complete the
vaccine series; 3 additional doses of vaccine (for
a total of four doses) should be administered according
to a recommended schedule on the basis of the mother's HBsAg test result. |
|
|
| Review the
hepatitis B vaccination recommendations for preterm infants
who weigh less than 2kg (4.4 pounds), as well as for those
premature infants who weigh more. |
|
Preterm infants
weighing less than 2 kg (4.4 lb) at birth have a decreased
response to hepatitis B vaccine administered before age 1
month. (By age 1 month, medically stable preterm infants,
regardless of initial birth weight or gestational age, have an
immunologic response to hepatitis B vaccination that is
comparable to that of full-term infants.) For preterm infants
weighing less than 2 kg at birth:
|
| • |
|
If maternal
HBsAg status is positive: Give hepatitis B immune
globulin (HBIG) plus hepatitis B vaccine within 12 hours
of birth. Give 3 additional hepatitis B vaccine doses
(with single-antigen vaccine at ages 1, 2–3, and 6
months, or hepatitis B-containing combination vaccine at
ages 2, 4, and 6 months [Pediarix] or 2, 4, and 12–15
months [Comvax]. Test for HBsAg and antibody to HBsAg
1–2 months after completion of at least 3 doses of a
licensed hepatitis B vaccine series (i.e., at age 9–18
months, generally at the next well-child visit). Testing
should not be performed before age 9 months nor within 4
weeks of the most recent vaccine dose. |
| • |
|
If
maternal HBsAg status is unknown: Give HBIG plus hepatitis B
vaccine within 12 hours of birth. Be sure to test the
mother’s blood for HBsAg. Give 3 additional hepatitis B
vaccine doses (with single-antigen vaccine at ages 1,
2–3, and 6 months, or hepatitis B-containing combination
vaccine at ages 2, 4, and 6 months [Pediarix] or 2, 4,
and 12–15 months [Comvax]. |
| • |
|
If the maternal HBsAg
status is negative: If you are certain that appropriate
testing was done and the mother’s test result is
negative, delay the first dose of hepatitis B vaccine
until age 1 month or hospital discharge. Complete the
vaccine series per the recommended schedule. |
|
For preterm infants weighing 2
kg or more at birth. For these preterm infants, follow the
recommendations for full-term infants including the birth dose
for all, keeping in mind the special needs of newborns whose
mother’s HBsAg status is positive or unknown. |
| |
| I'm a pediatrician
and support the use of the birth dose of hepatitis B
vaccine. I give it routinely, but a few parents object.
In my practice, almost 100% of my infant patients' mothers
are tested for HBsAg and almost all are reported to be
negative. Could you tell me how many cases of HBV infection
occur each year in babies who are born to documented
HBsAg-negative mothers? |
|
| Because infants born to HBsAg-negative
mothers are usually not tested for HBV infection, and because
virtually all HBV infections occurring among infants are
asymptomatic, it is not possible to quantify the number
of HBV-infected infants born to mothers believed to be
HBsAg negative. However, we know that many unvaccinated
newborns have been left needlessly at risk of infection
because of errors in maternal hepatitis B testing and reporting.
In two surveys conducted by IAC covering the period from
July 1999 to October 2002, state and local hepatitis B
coordinators reported more than 500 medical errors discovered
through their perinatal hepatitis B prevention programs.
Many of these errors involved misinterpreting or mistranscribing
hepatitis screening test results, or ordering the wrong
hepatitis B screening test. Such errors can lead to a mother
being documented as HBsAg negative, when she is actually
HBsAg positive. Use of the hepatitis B vaccine birth dose
safeguards against these maternal hepatitis B testing and
reporting errors and also prevents early childhood HBV
infections. The birth dose also protects the infants of
women who become HBV infected after having been screened
in early pregnancy and not tested later in pregnancy. |
|
| Preventing possible HBV transmission
in early childhood is also a major issue. Seroprevalence
data from the National Health and Nutrition Examination
Surveys have provided estimates of the number of early
HBV infections. Based on these data, approximately 16,000
children under 10 years of age were infected with HBV beyond
the postnatal period each year before routine infant vaccination
was recommended in 1991 (Armstrong GL, Mast EE, Wojczynski
M, Margolis HS. Childhood hepatitis B virus infections
in the United States before hepatitis B immunization. Ped.
200l;108(5):1123-28). Although these infections represented
only 5%-10% of all persons with chronic HBV infection in
the United States at that time, it is estimated that 18%
of all persons with chronic HBV infection acquired their
infections postnatally during early childhood. In some
populations, childhood transmission was more important
than perinatal transmission as a cause of chronic HBV infection
before infant hepatitis B immunization was widely implemented.
For example, in studies conducted among children born in
the United States with Southeast Asian refugee parentage
during the 1980s, approximately 60% of chronic HBV infections
in young children were among children born to HBsAg-negative
mothers. Since implementation of routine childhood immunization,
an estimated 6,800 perinatal HBV infections have been prevented
in the United States annually. |
|
| Why is it recommended
to give hepatitis B vaccine to infants when the greatest
numbers of cases occur in young adults? |
|
| Prior to the implementation
of routine infant hepatitis B immunization in the United
States, about 15,950 (range: 8,980-32,190) children under
age 10 years were infected with HBV annually. Two-thirds
of these children, who became infected with HBV during
childhood, did not have HBV-infected mothers. Perinatal
prevention programs that identify HBsAg-positive mothers
and that provide immunoprophylaxis to their infants would
not have prevented these infections. |
|
| In contrast to other vaccine-preventable
diseases of childhood, HBV infection in infants and young
children is usually asymptomatic. Thus, the small number
of reported cases of hepatitis B among children represents
the tip of the iceberg of all HBV infections in children.
For every child with symptoms of hepatitis B, there are
at least 100 children with asymptomatic HBV infection. |
|
| The birth dose that is recommended
routinely provides effective postexposure immunoprophylaxis
to prevent transmission in the perinatal period and early
infancy. Some of the reasons for this important recommendation
are as follows: |
|
| • |
|
HBsAg testing
of mothers does not identify all newborns that require
postexposure immunoprophylaxis. Errors are sometimes
made in ordering tests, reporting test results, and
omitting vaccination of infants of known HBsAg-positive
mothers. The birth dose serves as a "safety
net," preventing perinatal infection among infants
born to all mothers who are HBsAg positive and assures
protection for all infants. |
| • |
|
The birth
dose provides early protection to infants at risk
for infection after the perinatal period. Although
infections in young children represented less than
10% of all HBV infections before implementation of
routine childhood hepatitis B vaccination, childhood
infections resulted in an estimated 30–40% of chronic HBV infections among persons who acquired their infections
in the U.S. Many of these chronic infections would
not have been prevented by a selective program of
identification and immunization of only those infants
born to HBsAg-positive mothers. Based on the age-specific
risk of chronic HBV infection, it is estimated that
about one-third of the 1.25 million Americans with
chronic HBV infection acquired their infection as
infants or young children. Children who become chronically
infected have a 25% risk of dying prematurely from
liver cancer or cirrhosis. |
|
|
| Children born in the
United States continue to be infected with HBV. What
more can be done? |
|
| It is as simple as following
standard of care. All women should be screened for HBsAg
early with each pregnancy independent
of the woman's hepatitis B vaccination status. Testing
should be repeated if the woman has risk factors for HBV
infection, such as recent or current injection drug use
(IDU), having had more than one sex partner in the previous
6 months, an HBsAg-positive sex partner, or evaluation
or treatment for a sexually transmitted disease (STD).
If a risk factor is identified during pregnancy, the woman
should be started on the hepatitis B vaccine series right
away. Pregnancy is not a contraindication
to receiving hepatitis B vaccine. |
|
| CDC recommends that routine
infant hepatitis B vaccination should begin at birth. On
a case-by-case basis and only in rare circumstances, the
first dose may be delayed until after hospital discharge
for an infant who weighs at least 2 kg and whose mother
is HBsAg negative. A physician's order to withhold the
birth dose and a copy of the original laboratory report
indicating that the mother was HBsAg negative during this
pregnancy should be placed on the infant's medical record. |
|
| To prevent HBV transmission
among children at greatest risk for HBV infection, CDC also recommends that prenatal care providers, delivery
hospitals, and health departments implement policies and
procedures to identify and manage children born to HBV-infected
mothers and mothers with unknown HBV infection status.
The birth dose acts as a safety net if screening for HBsAg
is not performed, misordered, misinterpreted, or mistranscribed.
The birth dose also provides early protection to infants
at risk for infection after the perinatal period. In addition,
studies have shown that infants who receive the birth dose
of hepatitis B vaccine are more likely to complete their
childhood immunizations on schedule. |
|
| Should states and localities
establish case-management programs to prevent perinatal
HBV infection? |
|
| Yes. Case-management programs
should be established that include appropriate policies,
procedures, laws, and regulations to ensure that all pregnant
women are tested for HBsAg during each pregnancy and that
infants born to HBsAg-positive women and infants born to
women with unknown HBsAg status receive recommended case
management. The location of these programs and the methods
by which they operate will depend on multiple factors (e.g.,
population density and annual caseload of HBsAg-positive
women). Programs might be located in state or local health
departments, private healthcare systems (e.g., health maintenance
organizations), or institutions (e.g., correctional facility
systems). Program administrators will need to work with
prenatal care providers, delivery hospital staff, pediatric
care providers, private healthcare systems, and health
departments. |
|
| In the newborn nursery,
I had a parent insist on Recombivax HB for
their infant because Engerix B's
package insert reports that vaccine contains a "trace" amount
of thimerosal. Is there any thimerosal in this vaccine? |
|
| As of 1/30/2007, Engerix-B
is a thimerosal-free product. |
|
| Does a birth dose of
vaccine increase the risk of elevated temperature and
subsequent microbiologic evaluations? |
|
| No. Administration of hepatitis
B vaccine soon after birth has not been associated with
an increased rate of elevated temperatures or subsequent
evaluations for possible sepsis in the first 21 days of
life. |
|
| Is it safe for an HBsAg-positive
mother to breastfeed her infant? |
|
| Yes! An HBsAg-positive mother
who wishes to breastfeed should be encouraged to do so,
including immediately following delivery. However, the
infant should receive HBIG and hepatitis B vaccine within
12 hours of birth. Although HBsAg can be detected in breast
milk, studies done before hepatitis B vaccine was available
showed that breastfed infants born to HBsAg-positive mothers
did not demonstrate an increased rate of perinatal or early
childhood HBV infection. More recent studies have shown
that, among infants receiving postexposure prophylaxis
to prevent perinatal HBV infection, there is no increased
risk of infection among breastfed infants. |
|
| What is the possibility
of maternal HBV transmission when breastfeeding an infant
if the mother is HBsAg positive and has cracked or bleeding
nipples? |
|
| As stated before, although
HBsAg can be detected in breast milk, there is no evidence
that HBV is transmitted by breastfeeding. Babies born to
HBsAg-positive mothers should be immunized with hepatitis
B vaccine and HBIG, which will substantially reduce the
risk of perinatal transmission and protect the infant from
modes of postnatal HBV transmission, including the theoretical
exposure to HBV from cracked or bleeding nipples during
breastfeeding. To prevent cracked and bleeding nipples,
all mothers that breastfeed should be instructed on proper
nipple care. |
|
| Can Comvax or
Pediarix be given at birth? |
|
| No. Neither of these combination
vaccines should be given before age 6 weeks. The use
of Comvax prior to age 6 weeks can cause
the suppression of the immune response to the Hib component
in Comvax. The use of Pediarix prior
to age 6 weeks can result in suppression of the immune
response to the acellular pertussis component of Pediarix. |
|
| Is it acceptable to
give a 4-dose schedule of hepatitis B vaccine to infants? |
|
| Yes. The use of a 4-dose
hepatitis B vaccine schedule is necessary when giving the monovalent
hepatitis B vaccine birthdose followed by the use of combination
vaccines Comvax or Pediarix. The use of a 4-dose hepatitis
B vaccine schedule, including schedules with a birth dose,
has not increased vaccine reactogenicity and results in
higher final antibody titers that should correlate with
longer duration of detectable antibody. The federal VFC
program provides up to four doses of hepatitis B vaccine
for VFC-eligible children. You may still use monovalent
hepatitis B vaccine in a 3-dose series. |
|
|
An infant was
given monovalent hepatitis B vaccine (HepB) at birth. Later we
gave her monovalent HepB at age 1 month and age 4 months. Did
we give her the third dose too early? |
|
| Yes. Poorer immune response
rates are seen in infants who complete the vaccination series
prior to age 6 months. Do not count dose #3, which you gave at
age 4 months. Repeat dose #3 when the infant is at least age 6
months (no earlier than age 24 weeks). |
|
| What is the earliest
age the last dose of hepatitis B vaccine can be given
to an infant? |
|
| The minimum age for the last
dose of hepatitis B vaccine should not be prior to age
24 weeks. (The minimum age is the youngest age that is
acceptable for giving a vaccine and having it "count" as
a valid dose.) This change allows health professionals
more flexibility in administering hepatitis B vaccine should
a parent bring an infant in for a well-baby check before
the infant reaches a full 6 months of age. There is a 4-day
grace period for this dose; therefore, the earliest age
at which the last dose of hepatitis B vaccine is acceptable
is 164 days of age (168 days [24 weeks] minus the 4-day
grace period). If the third dose is given prior to the
minimum age, then that dose should not be counted. Poorer
response rates are seen in infants who complete the vaccination
series prior to age 24 weeks; therefore, the third dose
should be repeated when the infant is at least age 24 weeks. |
|
| An infant was given
monovalent hepatitis B vaccine at birth, at age 1 month,
and at age 4 months. Was the third dose given too early? |
|
| Yes, poorer response rates
are seen in infants who complete the vaccination series
prior to age 6 months. The dose given at age 4 months should
not be counted and the third dose should be repeated when
the infant is at least age 6 months (no earlier than 24
weeks). |
|
| What is the recommended time
to do hepatitis B testing for evidence of success or
failure of immunoprophylaxis given at birth to an infant
born to an HBsAg-positive mother? |
|
| For infants born to HBsAg-positive
mothers, postvaccination testing is recommended 1-2 months
after completion of at least 3 doses of a licensed hepatitis B
vaccine series (i.e., at age 9-18 months, generally at the
next well-child visit). Testing should not be performed before
age 9 months, as HBIG might still be present for 6-8 months
nor should testing be performed within 4 weeks of the most
recent vaccine dose, as a false positive HBsAg might occur.
Anti-HBc testing of infants is not recommended because
passively acquired maternal anti-HBc might be detected up to
age 24 months in infants of HBV-infected mothers. |
|
| HBsAg-negative infants with
anti-HBs levels of at least 10 mIU/mL are protected and need
no further medical management. HBsAg-negative infants with
anti-HBs levels less than 10 mIU/mL should be revaccinated
with a second 3-dose series and retested 1-2 months after the
final dose of vaccine. Infants who are HBsAg positive should
receive medical evaluation. |
|
| An infant of an HBsAg-positive
mother received appropriate postexposure prophylaxis and
tested negative for anti-HBs and HBsAg at 12 months of age.
How many more doses of hepatitis B vaccine do I need to give
before I retest? |
|
| The recommended approach is to
complete a second 3-dose series of vaccine and re-test for
both HBsAg and anti-HBs 1-2 months after the third dose of
vaccine. If anti-HBs and HBsAg are still negative after
revaccination, the infant is considered a non-responder to
hepatitis B vaccine. |
|
| When screening an adopted
infant for hepatitis B, at what age would you expect
the infant to not show anti-HBs or anti-HBc if it were
passively transferred antibody from the mother? |
|
| Passively acquired maternal
anti-HBs might be detected until age 6-8 months and passively
acquired maternal anti-HBc might be detected until age
24 months. |
|
| All foreign-born persons (including
immigrants, refugees, asylum seekers, and internationally
adopted children) born in Asia, the Pacific Islands, Africa,
and other regions with high endemicity of HBV infection
should be tested for HBsAg, regardless of vaccination status.
Persons testing HBsAg positive should be referred for medical
evaluation. |
|
| HBsAg-negative persons born
in high-endemic countries should be considered fully vaccinated
if they have written documentation of at least three doses
of vaccine administered at recommended minimum intervals,
including the third dose at age of at least 24 weeks. If
they were not vaccinated according to recommended minimum
intervals, they should be revaccinated. Persons without
written documentation of full vaccination should complete
the age-appropriate vaccine series. |
| |
|
|
|
Child and teen hepatitis B vaccination issues |
Back to top |
|
|
|
| Should all children
ages 0 through 18 years be vaccinated against hepatitis
B? |
|
| Yes. CDC recommends
that all children ages 0-18 years be fully vaccinated
with hepatitis B vaccine. This recommendation is also
endorsed by AAP and AAFP and is published as part of
the annual Recommended Childhood and Adolescent
Immunization Schedule (www.cdc.gov/vaccines/recs/schedules/child-schedule.htm). In
addition, CDC recommends that providers should implement
immunization record reviews for all children ages 11-12
years. Vaccination should be initiated for children not
previously vaccinated and vaccination completed for children
whose vaccine series is incomplete. |
| |
| All children and adolescents
less than age 19 years (including internationally adopted
children) who were born in Asia, the Pacific Islands, Africa,
or other intermediate-or high-endemic countries or who
have at least one parent who was born in one of these areas
should be screened for HBsAg and have a review of their
immunization record and should complete the vaccine series
if they were not previously vaccinated or were incompletely
vaccinated. |
|
| Some of my patients
weren't vaccinated for hepatitis B as infants. Must they
wait until ages 11-12 years before starting the series? |
|
| No. Children and adolescents
who have not previously received hepatitis B vaccine should
be vaccinated routinely at any age with the appropriate
dose and schedule. Selection of a vaccine schedule should
consider the need to achieve completion of the vaccine
series. In all settings, vaccination should be initiated,
even though completion of the vaccine series might not
be ensured. |
|
| Can adolescents, be
immunized on a 0-, 2-, 4-month schedule for hepatitis
B? |
|
| Yes. There are data that show
adequate seroprotection using this schedule in young adults.
If this schedule is used, you should be aware that the
studies were in young adults and might
not translate to older adults (equal or greater than 40
years). There are other schedules that offer flexibility
in vaccination, as well. View
www.immunize.org/catg.d/p2081.pdf for a review of
different schedules. |
|
| Three years ago at
a middle school, my patient received the first dose of
the hepatitis B vaccine series. Should I give her the
second dose now or do I need to start over again with
the first dose? |
|
| There is no need to restart
the series. Give the second dose now and be sure there
are at least 8 weeks between that dose and the third dose.
No apparent effect on immunogenicity has been documented
when minimum spacing of doses is not achieved precisely.
Increasing the interval between the first two doses has
little effect on immunogenicity or final antibody concentration.
The third dose confers the maximum level of seroprotection
but acts primarily as a booster and appears to provide
optimal long-term protection. Longer intervals between
the last two doses result in higher final antibody levels
but might increase the risk for acquisition of HBV infection
among persons who have a delayed response to vaccination.
No differences in immunogenicity have been observed when
one or two doses of hepatitis B vaccine produced by one
manufacturer are followed by doses from a different manufacturer. |
|
| Describe the 2-dose
regimen for hepatitis B vaccine for certain adolescents. |
|
| Using the approved 2-dose schedule,
the adult dose of Recombivax HB (1.0 mL
dose containing 10 mcg of HBsAg) is administered to adolescents
ages 11-15 years, with the second dose given 4-6 months
after the first dose. In immunogenicity studies among adolescents
ages 11-15 years, antibody concentrations and end seroprotection
rates (at least 10 mIU/mL of anti-HBs) were similar with
the 2-dose schedule and the currently licensed 3-dose schedule
(0.5 mL dose containing 5 mcg of HBsAg). The overall frequency
of adverse events was similar for the 2-dose schedule compared
to the 3-dose schedule. Short-term (two-year) follow-up
data indicate that the rate of decline in antibody levels
for the 2-dose schedule was similar to that for the 3-dose
schedule. No data are available to assess long-term protection
(beyond 2 years) or immune memory following vaccination
with the 2-dose schedule, and it is not known whether booster
doses of vaccine will be required. As with other hepatitis
B vaccination schedules, if administration of the 2-dose
schedule is interrupted, it is not necessary to restart
the series. Children and adolescents who have begun vaccination
with a dose of 5 mcg of Recombivax HB should
complete the 3-dose series with this dose. If it is not
clear which dose an adolescent was administered at the
start of a series, the series should be completed with
the 3-dose schedule. |
|
| How should we complete
the series if a 12-year-old child starts the 2-dose Recombivax
HB adult formulation series but fails
to receive dose 2 before his or her 16th birthday? |
|
| The 2-dose Recombivax HB schedule
is only licensed for use in children ages 11-15 years.
Thus, a 16-year-old child would need two additional doses
of pediatric hepatitis B vaccine to complete a 3-dose series. |
|
| I am confused
about the volume of hepatitis B vaccine dose to give
an adolescent. Is it 0.5 ml or 1.0 ml? |
|
| It depends on the schedule
and manufacturer that you are using. For 11-15 year old
children, the 2-dose Recombivax HB volume
is 1.0 mL or 10 micrograms. Otherwise the 3-dose schedule
of both Recombivax HB and Engerix B is
0.5 mL or 5 micrograms. IAC offers a handy resource with
charts detailing the correct dosages and schedules for
monovalent hepatitis B and hepatitis A vaccines and
combination products that include hepatitis A and hepatitis B
vaccines. Go to
www.immunize.org/catg.d/p2081.pdf. |
|
| I have some
Asian and African children and teens in my practice who were
born abroad. Should I test them all for hepatitis B, or just
make sure they are all vaccinated? |
|
| All foreign-born
persons (including immigrants, refugees, asylum seekers, and
internationally adopted children) born in Asia, the Pacific
Islands, Africa, and other regions with high endemicity of HBV
infection should be tested for HBsAg, regardless of
vaccination status. Initiating vaccination of immigrant
children should not be delayed while awaiting hepatitis B test
results. All persons found to be HBsAg positive should have
ongoing medical management by a physician knowledgeable about
hepatitis B and its complications. |
| |
|
|
|
|
| According to the CDC hepatitis B recommendations for adults,
which adults should be vaccinated? |
|
| The following groups are
recommended for hepatitis B vaccination: |
|
| • |
|
Sex partners
of HBsAg-positive persons |
| • |
|
Sexually
active persons who are not in long-term, mutually
monogamous relationships |
| • |
|
Persons seeking evaluation
or treatment for an STD |
| • |
|
Persons found to be anti-HBc
positive should be tested for HBsAg. HBsAg testing
may be performed on the same specimen collected for
anti-HBc testing. If the HBsAg test result is positive,
the person should receive appropriate management. |
| • |
|
Men who have sex with
men (MSM) |
| • |
|
Current or recent
illegal injection drug users |
| • |
|
Household contacts of
HBsAg-positive persons |
| • |
|
Residents and staff of
facilities for developmentally challenged persons |
| • |
|
Healthcare and public
safety workers with reasonably anticipated risk for
exposure to blood or blood-contaminated body fluids |
| • |
|
Persons with end-stage
renal disease, including predialysis, hemo-, peritoneal-,
and home-dialysis patients |
| • |
|
International travelers
to regions with intermediate or high levels of HBV
infection
Visit
http://wwwn.cdc.gov/travel/default.aspx for
countries with intermediate or high levels of HBV infection |
| • |
|
Persons with chronic
liver disease |
| • |
|
Persons with HIV infection |
| • |
|
All other persons who
wish to be protected from HBV infection |
|
|
| Acknowledgement of a specific
risk factor is NOT a requirement for vaccination. The official
CDC recommendations for hepatitis B vaccination of adults
are available at
www.cdc.gov/mmwr/PDF/rr/rr5516.pdf. |
|
| In which adult healthcare
setting(s) is hepatitis B vaccination recommended routinely? |
|
| In certain settings, a high
proportion of persons are likely to be at risk for HBV
infection. Examples of these settings are the following: |
|
| • |
|
STD/HIV testing
and treatment facilities |
| • |
|
Drug-abuse
treatment and prevention settings including injection-drug-user
care settings |
| • |
|
Healthcare settings targeting
services to MSM |
| • |
|
Correctional facilities |
| • |
|
Chronic hemodialysis
facilities and end-stage renal disease programs |
| • |
|
Institutions and non-residential
day care facilities for developmentally challenged
persons |
|
|
| In these settings, CDC recommends
universal hepatitis B vaccination for all adults who have
not completed the vaccine series. Certain persons with
risk factors (e.g., MSM and IDUs) should be vaccinated
against hepatitis A, as well. Although a risk assessment
is not required in these settings before offering and encouraging
hepatitis B vaccine, it still might be useful, and especially
for consideration of hepatitis A vaccine, given that not
all persons visiting these settings are recommended to
receive hepatitis A vaccine. |
|
| For your use, a hepatitis A
vaccination screening questionnaire is available at:
www.immunize.org/catg.d/p2190.pdf. A
hepatitis B vaccination screening questionnaire is available
at:
www.immunize.org/catg.d/p2191.pdf. |
|
| How should hepatitis B
vaccination be managed in
primary care and specialty medical settings? |
|
| In primary care and specialty
medical settings, CDC recommends implementation of standing
orders for identifying adults recommended for hepatitis
B vaccination and for administering vaccination as part
of routine services. To ensure vaccination of adults at
risk for HBV infection who have not completed the vaccine
series, CDC recommends the following: |
|
| • |
|
Provide information
to all adults regarding the health benefits of hepatitis
B vaccination, including risk factors for HBV infection
and persons for whom vaccination is recommended |
| • |
|
Help all
adults assess their need for vaccination by obtaining
a history that emphasizes risks for sexual transmission
and percutaneous or mucosal exposure to blood |
| • |
|
Vaccinate all adults
who report risk(s) for HBV infection |
| • |
|
Vaccinate all adults
requesting protection from HBV infection, without
requiring them to acknowledge a specific risk factor |
|
|
| For your use, a hepatitis B
vaccination screening questionnaire is available at
www.immunize.org/catg.d/p2191.pdf. Standing
orders for administering hepatitis B vaccine to adults
are also available at www.immunize.org/catg.d/p3076.pdf. |
|
| I want to be
able to start vaccinating adults at increased risk
of HBV infection in our clinic; however, we know that
many of them are uninsured or have minimal insurance
coverage. Is there any way that we can get free vaccine
from CDC? |
|
| The availability of free
vaccine is variable. Some states have
special programs that make hepatitis B vaccine available
for certain groups of adults with increased risk of HBV
infection. Check with your state immunization program
manager or hepatitis B coordinator on the availability
of low-cost or free vaccine. A list of state immunization
program managers and a
list of hepatitis B coordinators is available at:
www.immunize.org/coordinators. |
| |
| Is post-vaccination
testing needed for adults who receive hepatitis B vaccine? |
|
| Serologic testing for immunity after
vaccination is recommended only for persons whose subsequent
clinical management depends on knowledge of their immune
status. Testing is not necessary after routine vaccination
of adults. |
|
| Post-vaccination testing is
recommended for the following: Healthcare and public safety
workers at high risk of continued exposure to blood on
the job; immune compromised persons; and sex or needle-sharing
partners of HBsAg-positive persons. Testing should be performed
1-2 months after the last dose of vaccine. |
| |
| If a person has been
sexually assaulted, should he/she be offered HBIG and
hepatitis B vaccine? |
|
| There have been no studies
to determine the risk of HBV infection following sexual
assault; however, it is known that other STDs are transmitted
following such episodes. Therefore, post-exposure prophylaxis
to victims of sexual assault should be provided. Unless
the victim has a documented history of completed hepatitis
B vaccination, hepatitis B vaccine alone on a 0-, 1-, 6-month
vaccination schedule should be administered with the first
dose as soon as possible after the assault. There is no
need to give HBIG for the following reasons: 1) vaccine
alone has high efficacy in post-exposure prophylaxis in
persons exposed to chronic HBV infection; 2) HBIG is only
needed to improve efficacy of postexposure prophylaxis
of sex contacts of persons with acute HBV infection. In
most cases, it could be assumed that if the rapist were
HBV infected, he/she would have chronic HBV infection,
not acute HBV infection, and hence might be less infectious. |
|
| For details, please refer to
Appendix B of CDC's adult hepatitis B recommendations at:
www.cdc.gov/mmwr/PDF/rr/rr5516.pdf. |
| |
| How often do hemodialysis
patients who have received hepatitis B vaccination have
to be tested for anti-HBs and HBsAg? |
|
| Recommendations for immune
compromised persons, such as hemodialysis patients, are
different than those for immune competent people. Hemodialysis
patients who do not respond to an initial vaccine series
should be revaccinated with three or four additional doses
of hepatitis B vaccine (depending on the brand) using the
dialysis specific dosing regimen. Hemodialysis patients
are considered immune as long as they have adequate anti-HBs
(at least 10 mIU/mL). For hemodialysis patients who have
responded with adequate anti-HBs (postvaccination testing
should be done 1-2 months after the vaccine series) to
hepatitis B vaccination, no HBsAg testing is needed but
anti-HBs should be done annually. If anti-HBs declines
below 10 mIU/mL, a booster dose of hepatitis B vaccine
should be given and annual anti-HBs testing should be continued.
Retesting immediately after the booster dose is not necessary.
If the patient continues to have low (less than 10 mIU/mL)
or no anti-HBs and a total of six or eight doses (depending
on the brand) of hepatitis B vaccine have been given, the
patient should be considered a non-responder to vaccination
and susceptible to HBV infection. Monthly HBsAg testing
should be continued and no periodic anti-HBs testing is
needed. |
|
| I would like more information about
Twinrix, the combination hepatitis A and B vaccine. |
|
|
Twinrix (GlaxoSmithKline) is an inactivated
combination vaccine containing both hepatitis A virus
(HAV) and HBV antigens. The vaccine contains 720 EL.U. of hepatitis A antigen
(half of the Havrix
adult dose) and 20µg of hepatitis B antigen (the full Engerix-B adult dose). In
the U.S., Twinrix
is licensed for use in people who are age 18 years or older. It can be
administered to persons who
are at risk for both hepatitis A and hepatitis B, such as certain international
travelers, men who
have sex with men, illegal drug users, or to persons who simply want to be
immune to both diseases.
Primary immunization consists of 3 doses given intramuscularly on a 0, 1, and 6
month schedule. In
March 2007, the FDA also approved a 4-dose schedule for Twinrix. It consists of
3 doses given
within 3 weeks, followed by a booster dose at 12 months (0, 7 days, 21-30 days,
and 12 months). The
4-dose schedule could benefit individuals needing rapid protection from
hepatitis A and hepatitis
B, such as persons traveling to high-prevalence areas imminently and emergency
responders,
especially those being deployed to disaster areas overseas. Twinrix cannot be
used for postexposure
prophylaxis. |
|
|
I have seen adults who have had 1 or 2 doses of
Twinrix, but we only carry single-antigen vaccine in our practice. How should we
complete their vaccination series with single-antigen vaccines? |
|
Twinrix is licensed as a 3-dose series
for persons age 18 years and older. If Twinrix is not available or if
you choose not to use Twinrix to complete the Twinrix series, you should
do the following: If 1 dose of Twinrix was given, complete the series
with 2 adult doses of hepatitis B vaccine and 2 adult doses of hepatitis
A vaccine. If 2 doses of Twinrix were given, complete the schedule with
1 adult dose of hepatitis A vaccine and 1 adult dose of hepatitis B
vaccine.
Another way to consider this is as
follows:
A dose of Twinrix contains a standard adult dose of hepatitis B vaccine
and a pediatric dose of
hepatitis A vaccine. Thus, a dose of Twinrix can be substituted for any
dose of the hepatitis B
series but not for any dose of the hepatitis A series.
| • |
|
Any combination of 3 doses of adult
hepatitis B or 3 doses of Twinrix = a complete series of hepatitis B
vaccine |
| • |
|
One dose of Twinrix
+ 2 doses of adult hepatitis A = a complete series of
hepatitis A vaccine |
| • |
|
Two doses of Twinrix + 1
dose of adult hepatitis A = a complete series of
hepatitis A vaccine |
|
|
|
We're thinking of using Twinrix and we're
wondering whether we can use it for doses #1 and #3 only and use single antigen
hepatitis B vaccine for dose #2? |
|
| No. Twinrix contains 50% less hepatitis
A antigen component than Havrix, GSK's monovalent hepatitis A vaccine
[720 vs. 1440 El. U.], so the patient would not receive the recommended
dose of hepatitis A vaccine antigen. For this reason, 3 doses of Twinrix
must comprise the series. |
| |
|
|
|
|
| Which workers in the
healthcare setting need hepatitis B vaccine? |
|
| The Occupational Safety and
Health Administration (OSHA) requires that hepatitis B
vaccine be offered to HCWs who have a reasonable expectation
of being exposed to blood on the job. This requirement
does not include HCWs who would not be expected to have
occupational risk, such as receptionists, billing staff, and general office workers. |
|
| What are the recommendations
for postexposure prophylaxis after percutaneous or mucosal
exposure to HBV in an occupational setting? |
|
| The table below is from
"Management of Occupational Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure Prophylaxis," MMWR, June 29,
2001, Vol. 50, No RR-12.
www.cdc.gov/mmwr/PDF/rr/rr5011.pdf. |
|
| |
|
| For a pre-employment
physical, a HCW states she received all three hepatitis
B vaccine doses as an adolescent. Would you do a titer? |
|
| If the HCW has written documentation
of a full hepatitis B vaccine series, testing for anti-HBs
at this point is not necessary. If the HCW has a subsequent
exposure to HBV, hepatitis B immunoprophylaxis should be
administered following guidelines for a person who has been
vaccinated, but the immune response is not known (See
Table 3). This information should be documented in
the HCW's employee health record. This approach should
be sufficient to meet the needs of the employer and the
requirements of OSHA. If there is no written documentation
of hepatitis B vaccination, see the next question. |
|
| Several physicians
in our group have no documentation of having received
hepatitis B vaccine, but are relatively sure they received
the doses many years ago. What do we do now? |
|
| Because there is no documentation
of vaccination, the 3-dose vaccination series should be
administered and postvaccination testing should be performed
1-2 months after the third dose of vaccine. There is no
harm in receiving extra doses of vaccine. Care should always
be taken to document vaccine lot, date, manufacturer, route,
and vaccine dosages. Postvaccination testing results should
also be documented; including the date testing was performed.
All organizations (e.g., hospitals, clinics) should develop
policies or guidelines to assure valid hepatitis B immunization. |
|
| Which HCWs need serologic
testing after receiving 3 doses of hepatitis B vaccine? |
|
| All HCWs who have a reasonable
risk of exposure to blood or body fluids containing blood
should have postvaccination testing for anti-HBs (e.g.,
HCWs with direct patient contact, HCWs who have the risk
of needlestick or sharps injury, laboratory workers who
draw or test blood). Postvaccination testing should be
done 1-2 months after the last dose of vaccine. |
|
| How often should I
test HCWs after they've received the hepatitis B vaccine
series to make sure they're protected? |
|
| Periodic testing or periodic
boosting is not needed. Postvaccination testing should be done
1-2 months after the last dose of hepatitis B vaccine. If
adequate anti-HBs (at least 10 mIU/mL) is present, nothing
more needs to be done. If postvaccination testing is less than
10 mIU/mL, the vaccine series should be repeated and anti-HBs
testing done 1-2 months after the last dose of the second
series. |
|
| If the anti-HBs result is
still less than 10 mIU/mL, the HCW should be counseled on how
to protect him or herself from HBV infection and report any
exposure immediately to the proper department for
administration of HBIG, if needed. The HCW should also be
counseled that he/she might be HBsAg positive and should be
tested for same. This information should be recorded in the
HCW's employee health record. One caveat; if the HCW is immune
compromised, then yearly anti-HBs testing should be performed
to assure maintenance of seroprotection. |
|
| What should be done
if a HCW's serologic test comes back negative for anti-HBs
1-2 months after the last dose of vaccine? |
|
| Repeat the 3-dose series and
test for anti-HBs 1-2 months after the last dose of vaccine.
If the HCW is still negative after a second vaccine series,
the HCW is considered a non-responder to hepatitis B vaccination.
HCWs who do not respond to vaccination should be tested
for HBsAg to determine if they have chronic HBV infection.
If the HBsAg test is positive, the person should receive
appropriate counseling and medical management. Persons
who test negative for HBsAg should be considered susceptible
to HBV infection and should be counseled about precautions
to prevent HBV infection and the need to obtain HBIG prophylaxis
for any known or likely parenteral exposure to HBsAg-positive
blood. |
|
| How often should
anti-HBs testing be done on HCWs who perform invasive
procedures? |
|
| For persons whose immune
status is normal, periodic serologic testing to assess
anti-HBs levels is not necessary. Persons who perform
invasive procedures should be treated no differently
from other HCWs with respect to anti-HBs testing. If
a HCW has an exposure (e.g., needlestick) he or she should
be evaluated for postexposure immunoprophylaxis
according to current guidelines. These 2001 guidelines can be
accessed at:
www.cdc.gov/mmwr/PDF/rr/rr5011.pdf. |
|
| If a HCW had one dose
only of hepatitis B vaccine four months ago, should the
series be restarted? |
|
| No. The hepatitis B vaccine
series should not be restarted when doses are delayed;
rather, the series should be continued from where it stopped.
The HCW should receive the second dose of vaccine now and
the third dose at least 8 weeks later. There needs to be
at least 16 weeks between the first and the third doses
and at least 8 weeks between the second and third doses
of vaccine. |
|
| Is it safe for HCWs
to be vaccinated during pregnancy? |
|
| Yes. Limited data indicate
no apparent risk for adverse events to developing fetuses.
Current hepatitis B vaccines contain noninfectious hepatitis
B surface antigen (HBsAg) and should pose no risk to the
fetus. If the mother is being vaccinated because she is
at risk for HBV infection (e.g., a HCW, a person with an
STD, an IDU, multiple sex partners), vaccination should
be initiated as soon as her risk factor is identified during
the pregnancy. In contrast, HBV infection affecting a pregnant
woman might result in severe disease for the mother and
chronic infection for the newborn. In addition, hepatitis
B vaccination is not a contraindication to breastfeeding. |
|
| Before reading
the CDC recommendations that say not to do this, we
tested our employees for hepatitis B immunity (anti-HBs)
and some people had inadequate anti-HBs results, even
though they had all completed a 3-dose series. What
should we do now? |
|
| These persons might have
just lost detectable anti-HBs over time, but are still
protected. The most cost-effective approach is to do
nothing and if an exposure occurs, refer to the updated
recommendations for hepatitis B postexposure immunoprophylaxis
(Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HBV, HCV,
and HIV and Recommendations for Postexposure Prophylaxis.
6/29/01). These
guidelines can be accessed at:
www.cdc.gov/mmwr/PDF/rr/rr5011.pdf. |
|
| Another option would be to
give one dose of vaccine, test in 1 month and if anti-HBs
is adequate (at least 10 mIU/mL), nothing further needs
to be done. If anti-HBs is less than 10 mIU/mL, complete
the second series (2 more doses) and test 1-2 months after
the last dose and record the result in the HCW's employee
health record. |
|
| If an employee does
not respond to hepatitis B vaccination (employee has
two full series of hepatitis B vaccine), does s/he need
to be removed from activities that expose her/him to
bloodborne pathogens? Does the employer have a responsibility
in this area other than providing the vaccine? Where
can I get further information on this subject? |
|
| There are no regulations that
demand removal from certain job situations as described. The Occupational Safety and Health Administration
(OSHA) requires that employees in jobs where there is a
reasonable risk of exposure to blood be offered hepatitis
B vaccine. In addition, the regulation also states that
adequate personal protective equipment be provided and
that standard precautions be followed. Check with your
state OSHA regarding more stringent requirements. If there
is no state OSHA, federal OSHA regulations should be followed.
Adequate documentation should be placed in the employee
health record regarding non-response to vaccination. The
employee should be counseled that non-response to the vaccination
series most likely means that the employee is susceptible
to HBV infection and that if an exposure to HBV occurs,
HBIG should be used for post-exposure prophylaxis. HBsAg
testing should be recommended as it is possible that the
employee is chronically infected with HBV. Counseling of
the employee should then be done to discuss what non-response
to the vaccination series means for that specific employee
and what steps should be taken in the future to protect
her/his health. |
|
| If a person is a
non-responder (anti-HBs less than 10 mIU/mL) to the first
hepatitis B vaccination series, how much time needs to elapse
before the person can be revaccinated? |
|
| At least 4 weeks, as you
cannot determine whether the person is a non-responder until
anti-HBs is measured at a minimum of 4 weeks following the
last dose of the first vaccination series. |
|
| What is the percentage
of persons who respond to revaccination? |
|
| Among a sample of
vaccinated persons, 56-62% were positive for neutralizing
antibody 14 days after the first dose, and 94-100% were
positive at one month. Other studies show that 25-50% of persons respond
to an additional vaccine dose and 50-75% respond to a
3-dose revaccination series given on a 0, 2, 6-month schedule.
Persons who fail to develop protective levels of anti-HBs
1-2 months after revaccination either are primary non-responders
or are infected with HBV. No data suggest that persons
who fail to develop detectable antibody after 6 doses of
vaccine would benefit from additional doses. |
|
|
| How should a vaccinated
HCW with an unknown anti-HBs response be managed if they
have a percutaneous or mucosal exposure to blood or body
fluids from an HBsAg-positive source? |
|
| These persons should be tested
for anti-HBs as soon as possible after exposure. If the
anti-HBs concentration is at least 10 mIU/mL, no further
treatment is needed. If the anti-HBs concentration is less
than 10 mIU/mL, HBIG and hepatitis B vaccine should be
administered. In addition, the person should receive postvaccination
anti-HBs testing in 3-6 months. It is necessary to do postvaccination
testing later than the usual recommended time frame of
1-2 months because anti-HBs from HBIG might be detected
if testing is done earlier. The postvaccination test
result should be recorded in the person's health record. (See
Table 3). |
|
| A person who is a "known
non-responder" to hepatitis B vaccine has a percutaneous
exposure to HBsAg-positive blood. According to CDC recommendations,
I have the option to give HBIG x 2 or HBIG x 1 and initiate
revaccination. How do I decide which to do? |
|
| Current recommendations have
been revised. The recommended postexposure prophylaxis for
persons who are non-responders to hepatitis B vaccine (i.e.,
have not responded to an initial 3-dose series and
revaccination with a 3-dose series) is to give HBIG as soon as
possible after exposure and a second dose of HBIG one month
later. Exposed persons, who are known not to have responded to
a primary vaccine series, but have not been revaccinated with
a second 3-dose series, should receive a single dose of HBIG
and reinitiate the hepatitis B vaccine series with the first
dose of hepatitis B vaccine as soon as possible after
exposure. Postvaccination testing
should not be done for at least 3-6 months after this second
series as HBIG might be measured instead of vaccine induced
anti-HBs (see
Table 3). |
|
| How many days after
a percutaneous exposure can HBIG be given? Our lab doesn't
provide blood results until seven days after the blood
is drawn. Should we wait to give HBIG, or should we go
ahead with HBIG and hepatitis B vaccine? |
|
| If you must wait on testing
to determine the source's HBsAg status, vaccine should
be started immediately while awaiting test results. HBIG
can then be given within seven days, if the source is HBsAg
positive. Considering the type of tests that are available
today, laboratories should be capable of reporting results
back to you within seven days. We would not give HBIG farther
out than seven days from an exposure to HBsAg-positive
blood. The hepatitis B vaccine series should be completed
and would offer good protection alone. |
|
| If the HCW had been vaccinated
and had developed adequate anti-HBs, this would not be
an issue. If the exposure is to known HBsAg-positive blood
and the HCW was not vaccinated, a single dose of HBIG (0.06mL/kg)
should be given as soon as possible after exposure (within
24 hours, if possible). The first dose of hepatitis B vaccine
should be administered at a different site, but at the
same time as the HBIG. The vaccine series should be completed
according to current recommendations. |
|
| If the HCW is a true non-responder
to vaccine (failure to develop adequate anti-HBs after
two full hepatitis B vaccine series), the preferred postexposure
prophylaxis regimen is to give HBIG (0.06 mL/kg) as soon
as possible and a second dose one month later. |
| |
|
|
|
|
| What does the term "chronic
hepatitis B virus infection" mean? |
|
| Chronic infection with HBV
means that you have a long-term HBV infection; your body
did not get rid of the virus when you were first infected
with HBV. The risk of progressing to chronic infection
is age dependent (i.e., 2% to 6% of people over age 5
years; 30% of children age 1-5 years; and up to 90% of
infants). People with chronic infection can infect others
and are at increased risk of serious liver disease including
cirrhosis and liver cancer. In the United States, an estimated
1.25 million people are chronically infected with HBV. |
|
| A person is
considered to have chronic HBV infection if he or she is (1)
HBsAg positive on two occasions at least 6 months apart, or
(2) HBsAg positive and IgM class anti-HBc (antibody to
hepatitis B core antigen) negative on a single blood draw. (An
IgM class anti-HBc test will be positive for 4–6 months after
acute HBV infection.) |
|
| What are some important
Do’s and Don’ts for people with chronic HBV infection? |
|
| DO’s |
|
| • |
|
Cover all
cuts and open sores with a bandage. |
| • |
|
Discard used
items such as bandages and menstrual pads carefully
so no one is accidentally exposed to your blood. |
| • |
|
Wash hands well after
touching your blood or infectious body fluids. |
| • |
|
Clean up blood spills.
Then clean the area again with a bleach solution
(one part household chlorine bleach to 10 parts of
water). |
| • |
|
Tell your sex partner(s)
you have hepatitis B so they can be tested and vaccinated
(if not already infected or vaccinated). Partners
should be tested after three doses of vaccine are
completed to be sure the vaccine worked. |
| • |
|
Use condoms (rubbers)
during sex unless your sex partner has had hepatitis
B or has been immunized and has had a blood test
demonstrating immunity to HBV infection. (Condoms
might also protect you from other sexually transmitted
diseases). |
| • |
|
Tell household members
to see their doctors for testing and vaccination
for hepatitis B. |
| • |
|
Tell your doctors that
you are chronically infected with HBV. |
| • |
|
See your doctor every
6-12 months to check your liver for abnormalities,
including cancer. |
| • |
|
If you are pregnant,
tell your doctor that you have HBV infection. It
is critical that your baby is started on hepatitis
B shots within a few hours of birth. |
|
|
| DONT’s |
|
| • |
|
Don’t share
chewing gum, toothbrushes, razors, washcloths, needles
for ear or body piercing, or anything that might
have come in contact with your blood or infectious
body fluids. |
| • |
|
Don’t pre-chew
food for babies. |
| • |
|
Don’t share syringes
and needles. |
| • |
|
Don’t donate blood, plasma,
body organs, tissue, or sperm. |
|
|
| Should all HBsAg-positive
adults and children be referred to specialists in liver
disease (e.g., hepatologists)? |
|
| All HBsAg-positive adults and
children should have a medical evaluation to determine
whether they have active liver disease (e.g., liver enzymes,
biochemical tests of liver function) and whether they are
candidates for antiviral therapy. Depending on your practice
situation or setting, this can be done by referral or consultation
with a physician knowledgeable about chronic viral hepatitis
(i.e., hepatologist, infectious disease specialist, gastroenterologist). |
|
| I understand that if
a person is HBeAg negative and HBsAg positive, s/he is
not infectious. Am I correct? |
|
| No, you are incorrect! HBsAg-positive
people are infectious independent of their HBeAg status.
HBeAg-positivity indicates higher levels of HBV in the
blood compared to an HBeAg-negative person. A person who
is HBsAg positive and HBeAg negative is still infectious,
but has lower levels of HBV in their blood. |
|
| I have had patients
tell me that their doctor said their HBV infection is "in
remission." Would you please comment on the appropriateness
of this terminology? |
|
| "Remission" is not a good term
to be used for a persistent infection, such as HBV. HBV
infection should be described in terms of virologic markers,
infectivity, and evidence of liver disease. Some persons
might resolve their infection (i.e., become HBsAg negative,
and hence are not infectious) spontaneously or from antiviral
therapy. Other persons might remain HBsAg positive and
hence infectious, but have no evidence of chronic liver
disease (i.e., the often used term "healthy carriers").
We assume that the use of "remission" in the question might
refer to either of these scenarios. |
|
| Does giving hepatitis
B vaccine to a chronically infected person cause any
harm? |
|
| No, it will neither harm nor
help the person. |
|
| What are possible risk
factors for developing liver disease among persons with
chronic HBV infection? |
|
| Older age, male gender, presence
of HBeAg, HBV genotype, mutations in the precore and core
promoter regions of the viral genome, and coinfection with
hepatitis D (delta) virus. An association between alcohol
use and progression to hepatocellular carcinoma in persons
with chronic hepatitis B has been reported in some studies,
but not in others; these discrepancies might be related
to accuracy of the alcohol history. |
|
| Can a person
with chronic HBV infection become a HCW? |
|
| Yes. All HCWs should practice
standard precautions, which are designed to prevent HBV transmission,
both from patients to HCW and from HCW to patient. There is,
however, one caveat concerning HBV-infected HCWs. Those who
are HBsAg positive and HBeAg positive should not perform exposure-prone
procedures (e.g., gynecologic, cardiothoracic surgery) unless
they have sought counsel from an expert review panel and been
advised under what circumstances, if any, they may continue
to perform these procedures. Such circumstances might include
notifying prospective patients of the HCW's seropositivity
before they undergo exposure-prone invasive procedures. For
more information on this issue, see the MMWR 2001
recommendations. This document is available at
www.cdc.gov/mmwr/PDF/rr/rr5011.pdf. |
|
| We have a 12-year-old
patient who has been HBsAg positive since infancy. Now
that the state requires proof of hepatitis B vaccination,
what do we do? His mom is less than enthusiastic about
telling the school that he is HBsAg positive, and I can't
find any recommendations on vaccinating kids in this
situation. |
|
| We would not vaccinate the
child. You should check with your state health department,
as states might be different in what they require for declination
of vaccination. Depending on state regulations, as the
child's physician, you could provide the school with a
letter stating that hepatitis B vaccination is contraindicated
for the child. There is no need to add that the child is
HBsAg positive. |
| |
| Reviewed on 6/09 by IAC staff |
|
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