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Hepatitis B

Adapted from: CDC.  Protection against viral hepatitis.  MMWR 1990; 39 (No. RR-2):17-22.
Immunization of Health Care Workers. MMWR 1997; 46 (No. RR-18):22-23.

Abbreviations:
anti-HBs: hepatitis B surface antibody
HBeAg: hepatitis B e antigen
HBIG: hepatitis B immune globulin
HBsAg: hepatitis B surface antigen
HBV: hepatitis B virus
HCW: health care worker
IG: immune globulin

Table: Recommended postexposure prophylaxis for percutaneous or permucosal exposure to hepatitis B virus

 Treatment when source is:

Vaccination and antibody response status of exposed person

HBsAg*
POSITIVE

HBsAg
NEGATIVE

Source not tested or status unknown

Unvaccinated HBIG x 1; initiate HB vaccine series§ Initiate HB vaccine series Initiate HB vaccine series
Previously vaccinated

Known responder 

No treatment No treatment No treatment

Known non-responder

HBIG x 2 or
HBIG x 1 and initiate revaccination
No treatment If known high-risk source, treat as if source were HBsAg positive

Antibody response unknown

Test exposed person for anti-HBs**
1. If adequate, no treatment

2. If inadequate, HBIG x 1 and vaccine booster

No treatment Test exposed person for anti-HBs
1. If adequate, no treatment

2. If inadequate, initiate revaccination

* Hepatitis B surface antigen.
 Hepatitis B immune globulin; dose 0.06 mL/kg intramuscularly.
§ Hepatitis B vaccine.
¶ Responder is defined as a person with adequate levels of serum antibody to hepatitis B surface antigen (i.e., anti-HBs > 10 mlU/mL); inadequate response to vaccination defined as serum anti-HBs < 10 mlU/mL.
** Antibody to hepatitis B surface antigen.

Introduction

Prophylactic treatment to prevent infection after exposure to HBV should be considered in the following situations: perinatal exposure of an infant born to an HBsAg-positive mother, inadvertent percutaneous or permucosal exposure to HBsAg-positive blood, sexual exposure to an HBsAg-positive person, and household exposure of an infant less than 12 months of age to a primary caregiver who has acute hepatitis B.

Various studies have established the relative efficacies of HBIG and/or hepatitis B vaccine in different exposure situations. For an infant with perinatal exposure to an HBsAg-positive and HBeAg-positive mother, a regimen combining one dose of HBIG at birth with the hepatitis B vaccine series started soon after birth is 85%-95% effective in preventing development of the HBV carrier state (A1-A3). Regimens involving either multiple doses of HBIG alone or the vaccine series alone have 70%-90% efficacy (A4, A5).

For inadvertent percutaneous exposure, only regimens including HBIG and/or immune globulin (IG) have been studied. A regimen of two doses of HBIG, one given after exposure and one a month later, is about 75% effective in preventing hepatitis B in this setting (A6, A7). For sexual exposure to a person with acute hepatitis B, a single dose of HBIG is 75% effective if administered within 2 weeks of last sexual exposure (A8). The efficacy of IG for postexposure prophylaxis is uncertain; IG no longer has a role in postexposure prophylaxis of hepatitis B because of the availability of HBIG and the wider use of hepatitis B vaccine.

Health Care Workers

Any HCW who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated. Hepatitis B vaccine should always be administered by the intramuscular route in the deltoid muscle with a needle 1-1.5 inches long.

Among health-care professionals, risks for percutaneous and permucosal exposures to blood vary during the training and working career of each person but are often highest during the professional training period. Therefore, vaccination should be completed during training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions, before trainees have contact with blood. In addition, the OSHA Federal Standard requires employers to offer hepatitis B vaccine free of charge to employees who are occupationally exposed to blood or other potentially infectious materials.

Prevaccination serologic screening for previous infection is not indicated for persons being vaccinated because of occupational risk unless the hospital or health-care organization considers screening cost-effective. Postexposure prophylaxis with hepatitis B immune globulin (HBIG) (passive immunization) and/or vaccine (active immunization) should be used when indicated (e.g., after percutaneous or mucous membrane exposure to blood known or suspected to be HBsAg-positive [Table]).

Needlestick or other percutaneous exposures of unvaccinated persons should lead to initiation of the hepatitis B vaccine series. Postexposure prophylaxis should be considered for any percutaneous, ocular, or mucous membrane exposure to blood in the workplace and is determined by the HBsAg status of the source and the vaccination and vaccine-response status of the exposed person.

If the source of exposure is HBsAg-positive and the exposed person is unvaccinated, HBIG also should be administered as soon as possible after exposure (preferably within 24 hours) and the vaccine series started.  The effectiveness of HBIG when administered>7 days after percutaneous or permucosal exposures is unknown. If the exposed person had an adequate antibody response (>10 mlU/mL) documented after vaccination, no testing or treatment is needed, although administration of a booster dose of vaccine can be considered.

One to 2 months after completion of the 3-dose vaccination series, HCWs who have contact with patients or blood and are at ongoing risk for injuries with sharp instruments or needlesticks should be tested for antibody to hepatitis B surface antigen (anti-HBs). Persons who do not respond to the primary vaccine series should complete a second three-dose vaccine series or be evaluated to determine if they are HBsAg-positive. Revaccinated persons should be retested at the completion of the second vaccine series. Persons who prove to be HBsAg-positive should be counseled accordingly. Primary non-responders to vaccination who are HBsAg-negative should be considered susceptible to HBV infection and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood. Booster doses of hepatitis B vaccine are not considered necessary, and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series is not recommended.

Sex Partners of Persons with Acute Hepatitis B Virus Infection

Sex partners of HBsAg-positive persons are at increased risk of acquiring HBV infection, and HBIG has been shown to be 75% effective in preventing such infections (A8). Because data are limited, the period after sexual exposure during which HBIG is effective is unknown, but extrapolation from other settings makes it unlikely that this period would exceed 14 days. Before treatment, testing sex partners for susceptibility is recommended if it does not delay treatment beyond 14 days after last exposure. Testing for anti-HBc is the most efficient prescreening procedure to use in this population.

All susceptible persons whose sex partners have acute hepatitis B infection should receive a single dose of HBIG (0.06 mL/kg) and should begin the hepatitis B vaccine series if prophylaxis can be started within 14 days of the last sexual contact or if sexual contact with the infected person will continue. Administering the vaccine with HBIG may improve the efficacy of post exposure treatment. The vaccine has the added advantage of conferring long-lasting protection.

An alternate treatment for persons who are not from a high-risk group for whom vaccine is routinely recommended and whose regular sex partners have acute HBV infection is to administer one dose of HBIG (without vaccine) and retest the sex partner for HBsAg 3 months later. No further treatment is necessary if the sex partner becomes HBsAg negative. If the sex partner remains HBsAg positive, a second dose of HBIG should be given and the hepatitis B vaccine series started.

Household Contacts of Persons with Acute Hepatitis B Virus Infection

Since infants have close contact with primary caregivers and they have a higher risk of becoming HBV carriers after acute HBV infection, prophylaxis of an infant less than 12 months of age with HBIG (0.5 mL) and hepatitis B vaccine is indicated if the mother or primary caregiver has acute HBV infection. Prophylaxis for other household contacts of persons with acute HBV infection is not indicated unless they have had identifiable blood exposure to the index patient, such as by sharing toothbrushes or razors. Such exposures should be treated like sexual exposures. If the index patient becomes an HBV carrier, all household contacts should receive hepatitis B vaccine.

*An adequate antibody level is > 10mIU/mL.

References
A1. Stevens CE, Taylor PE, Tong MJ, et al. Yeast-recombinant hepatitis B vaccine: efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission. JAMA 1987;257:2612-6.
A2. Beasley RP, Hwang L-Y, Lee G-C, et al. Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B vaccine. Lancet 1983;2:1099-102.
A3. Stevens CE, Toy P, Tong MJ, et al. Perinatal hepatitis B virus transmission in the United States: prevention by passive-active immunization. JAMA 1985;253:1740-5
A4. Beasley RP, Hwang L-Y, Stevens CE, et al. Efficacy of hepatitis B immune globulin for prevention of perinatal transmission of the hepatitis B virus carrier state: final report of a randomized double-blind, placebo-controlled trial. Hepatology 1983;3:135-41
A5. Xu Z-Y, Liu C-B, Francis DP, et al. Prevention of perinatal acquisition of hepatitis B virus carriage using vaccine: preliminary report of a randomized, double-blind placebo-controlled and comparative trial. Pediatrics 1985;76:713-8.
A6. Seeff LB, Wright EC, Zimmerman HJ, et al. Type B hepatitis after needlestick exposure. Prevention with hepatitis B immune globulin: final report of the Veterans Administration Cooperative Study. Ann Intern Med 1978;88:285-93.
A7. Grady GF, Lee VA, Prince AM, et al. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multi-center controlled trial. J Infect Dis 1978; 138:625-38.
A8. Redeker AG, Mosley JW, Gocke DJ, McKee AP, Pollack W. Hepatitis B immune globulin as a prophylactic measure for spouses exposed to acute type B hepatitis. N Engl J Med 1975;293:1055-9.

Additional resources