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HEPATITIS B

VACCINATION
dr. Putri Nugraheni

Epidemiology

An estimated 350 million persons worldwide are


chronically infected with HBV.
In the United States, there are an estimated 1.25
million hepatitis B carriers, dened as persons
positive for hepatitis B surface antigen (HBsAg)
for more than 6 months.
Carriers of HBV are at increased risk of
developing cirrhosis, hepatic decompensation,
and hepatocellular carcinoma (HCC).

About Hepatitis B

HBV is a 42-nm DNA virus classied in the


Hepadnaviridae family. The liver is the primary
site of HBV replication. After a susceptible person
is exposed, the virus enters the liver via the
bloodstream
HBV infection can produce either asymptomatic or
symptomatic infection. The average incubation
period is 90 days (range: 60150 days) from
exposure to onset of jaundice and 60 days (range:
4090 days) from exposure to onset of abnormal
serum alanine aminotransferase (ALT) levels

When present, clinical symptoms and


signs can include anorexia, malaise,
nausea, vomiting, abdominal pain, and
jaundice. Extrahepatic manifestations of
disease (e.g., skin rashes, arthralgias,
and arthritis) also can occur

Transmission

HBV is transmitted by perinatal, percutaneous,


and sexual exposure, as well as by close
person-to-person contact presumably by open
cuts and sores, especially among children in
hyperendemic areas.
The risk of developing chronic HBV infection
after acute exposure ranges from 90% in
newborns of HBeAg-positive mothers to 25%
to 30% in infants and children under 5 and to
less than 5% in adults.

Table 2. Groups at High Risk for HBV Infection Who Should


Be Screened :

Individuals born in areas of high* or intermediate prevalence


rates forHBV including immigrants and adopted children

Asia: All countries


Africa: All countries
South Pacic Islands: All countries
Middle East (except Cyprus and Israel)
European Mediterranean: Malta and Spain
The Arctic (indigenous populations of Alaska, Canada, and
Greenland)
South America: Ecuador, Guyana, Suriname, Venezuela, and
Amazon regions of Bolivia, Brazil, Colombia, and Peru
Eastern Europe: All countries except Hungary
Caribbean: Antigua and Barbuda, Dominica, Granada, Haiti,
Jamaica, St. Kitts and Nevis, St. Lucia, and Turks and Caicos.

Other groups recommended for screening

Born persons not vaccinated as infants whose parents were


born in regions with high HBV endemicity (8%)
Household and sexual contacts of HBsAg-positive persons
Persons who have ever injected drugs
Persons with multiple sexual partners or history of sexually
transmitted disease
Men who have sex with men
Inmates of correctional facilities
Individuals with chronically elevated ALT or AST
Individuals infected with HCV or HIV
Patients undergoing renal dialysis
All pregnant women
Persons needing immunosuppressive therapy

Prevention

Hepatitis B vaccination is the most effective


measure to prevent hepatitis B virus (HBV)
infection and its consequences, including cirrhosis
of the liver, liver cancer, liver failure, and death.
In adults, ongoing HBV transmission occurs
primarily among unvaccinated persons with
behavioral risks for HBV transmission (e.g.,
heterosexuals with multiple sex partners, injectiondrug users [IDUs], and men who have sex with
men [MSM]) and among household contacts and
sex partners of persons with chronic HBV infection.

Before hepatitis B vaccination was widely


implemented, HBV infection was recognized as
a common occupational hazard among persons
who were exposed to blood while caring.
Since then, routine hepatitis B vaccination of
health-care workers and use of standard
precautions to prevent exposure to bloodborne pathogens have made HBV infection a
rare event in these populations.
Since the mid-1990s, the incidence of HBV
infection among health-care workers has been
lower than that among the general population.

During 2000 - 2004, self-reported


hepatitis B vaccination coverage among
adults at risk for HBV infection increased
from 30% to 45%
This increase in vaccination coverage
likely contributed to the 35% decline in
acute hepatitis B incidence that occurred
during this period (from 3.7 to 2.4 per
100,000 population).

HBIG and concurrent hepatitis B vaccine have


been shown to be 95% efcacious in the
prevention of perinatal transmission of HBV, the
efcacy is lower for maternal carriers with very
high serum HBV DNA levels (>8 log10 IU/mL).
Transmission of HBV from infected health care
workers to patients has also been shown to occur
in rare instances.
Follow-up testing is recommended for those who
remain at risk of infection such as health care
workers, infants of HBsAg-positive mothers and
sexual partners of persons with chronic HBV
infection.

Recommendation
A comprehensive strategy to eliminate HBV
transmission:
1) universal vaccination of infants beginning at birth
2) prevention of perinatal HBV infection through routine
screening of all pregnant women for hepatitis B
surface antigen (HBsAg) and postexposure
immunoprophylaxis of infants born to HBsAg-positive
women or to women with unknown HBsAg status
3) vaccination of all children and adolescents who were
not vaccinated previously
4) vaccination of previously unvaccinated adults at risk
for HBV infection

In settings in which a high proportion of


adults have risks for HBV infection (e.g.,
sexually transmitted disease/human
immunodeciency virus testing and
treatment facilities, drug-abuse treatment
and prevention settings, health-care settings
targeting services to IDUs, health-care
settings targeting services to MSM, and
correctional facilities), ACIP recommends
universal hepatitis B vaccination for all
unvaccinated adults.

Recommendations for Counseling and Prevention of


Transmission of Hepatitis B from Individuals with Chronic
HBV Infection:

Carriers should be counseled regarding prevention of


transmission of HBV (Table 3). (III)

Sexual and household contacts of carriers who are negative


for HBV seromarkers should receive hepatitis B vaccination.
(III)

Newborns of HBV-infected mothers should receive HBIG and


hepatitis B vaccine at delivery and complete the
recommended vaccination series. (I)

Persons who remain at risk for HBV infection such as infants


of HBsAg-positive mothers, health care workers, dialysis
patients, and sexual partners of carriers should be tested
for response to vaccination. (III)

Vaccination

Hepatitis B vaccine is available as a singleantigen formulation and also in xed


combination with other vaccines.
HBsAg is the antigen used for hepatitis B
vaccination.
>3 intramuscular doses of hepatitis B vaccine
0, 1, and 6 months
protective antibody response in approximately
30%55% of healthy adults aged <40 years
after the rst dose, 75% after the second dose,
and >90% after the third dose

Postvaccination

Postvaccination testing is recommended


for certain health-care and public safety
workers; chronic hemodialysis patients,
HIV-infected persons, and other
immunocompromised persons; and sex
or needle-sharing partners of HBsAgpositive persons

revaccination occurs in persons who have


measurable but low (<10 mIU/mL) levels of
antibody after the initial series.
After primary immunization with hepatitis B
vaccine, anti-HBs levels decline rapidly within
the rst year and more slowly in the next 1015 years.
Even when anti-HBs concentrations decline to
<10 mIU/mL, nearly all vaccinated persons
remain protected against HBV infection.

Conclusion

Hepatitis B is a highly infectitious


disease which can cause end-stage
complications
Transmission route includes contact with
cuts, sores, and blood
Health care provider is at all times at risk
of getting hepatitis B infection
Transmission can be prevented by
vaccination
All health care providers are
recommended to have routine screening

References

Lok ASF, McMahon BJ. AASLD Practice


Guidelines, Chronic Hepatitis B Update.
2009.
Alter MJ, et al. A Comprehensive
Immunization Strategy to Eliminate
Transmission of Hepatitis B Virus
Infection in the United States. 2006.

THANK YOU