There are two components to preventing hepatitis B:
- Prevention of transmission of the virus.
Hepatitis B virus (HBV) is usually spread by intimate sexual contact or parenterally. This is usually from blood or blood products, whether by intentional transfusion or sharing injection equipment or implements for tattooing. It can also be transmitted through perinatal transmission from mother to child.
Exposure to HBV can produce a variety of different states:
- 60-65% show subclinical disease and recover fully.
- 20-25% develop acute hepatitis
- 5-10% become 'healthy' carriers, ie hepatitis B surface antigen (HBsAg)-positive after six months.
- 5-10% develop chronic hepatitis.
- Those that carry the HBsAg are not at high risk of transmitting the disease, unless they also carry the hepatitis B e antigen (HBeAg).
- Carriers of HBeAg are very infectious.
See separate Hepatitis B article.
Prevention of transmission
- Practise safe sex.
- Avoid sharing intravenous drug paraphernalia.
- Immunise at-risk individuals.
- Wear gloves when exposed to blood or body fluids.
- Clear up blood or body fluids, using warm water and detergent.
- Ensure surgical instruments are disposable or adequately sterilised.
- Handle 'sharps' safely.
- Wear goggles if there is risk of infected material splashing into the eye.
- Do not permit healthcare workers (who are positive for hepatitis B e antigen (HBeAg)) to work in areas where they could be a risk to others.
- The vaccine contains hepatitis B surface antigen (HBsAg) adsorbed on to aluminium hydroxide adjuvant.
- There is also a combined vaccine available with provides protection against hepatitis A and hepatitis B.
- Hepatitis B vaccine is safe and effective, but should not be seen as an alternative to a strategy of prevention of transmission.
- Those who may be exposed to blood or blood products through their occupation, eg healthcare workers, ambulance crews, carers of high-risk or known patients, and morticians.
- Travellers who intend to stay for long periods in high-prevalence areas.
- Those considered to be at risk of hepatitis B through their planned activities, eg volunteers undertaking manual work, taking part in contact sports, involvement with casual sex.
- Those individuals who change sexual partners frequently.
- Travellers with pre-existing medical conditions, who may be at higher risk of requiring medical procedures abroad, eg pregnancy. (Pregnancy is not a contra-indication to immunisation.)
- Injecting drug users.
- Partners and children of injecting drug users.
- Non-injecting drug users who live with injecting drug users.
- Individuals in residential accommodation for those with learning difficulties.
- People travelling to or going to reside in areas of high or intermediate prevalence..
- Haemophiliacs requiring treatment and those who are receiving regular blood or blood products.
- Prisoners and prison officers.
- Family contacts of those with chronic hepatitis B infection.
- Those patients with chronic kidney disease or chronic liver disease.
- All pregnant women should be screened for hepatitis B virus (HBV):
- If positive, the baby should receive vaccination soon after birth.
- Babies born to highly infectious mothers should also receive hepatitis B immunoglobulin.
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- The standard course of immunisation involves three injections at 0, 1 and 6 months.
- An accelerated course of 0, 1 and 2 months is possible - also for combined hepatitis A and B vaccines.
- Adults who need protection very quickly (eg within 48 hours of exposure) can have a schedule of 0, 7 and 21 days. After an accelerated course, a booster at one year is recommended.
- The duration of protection provided by the hepatitis B vaccine is still unknown.
- It is quite possible that a course may give lifelong immunity. However, it is recommended that individuals at continuing risk of infection should be offered a single booster dose of vaccine, once only, around five years after primary immunisation. Measurement of hepatitis B surface antibody (anti-HBs) levels is not required either before or after this dose.
Testing for hepatitis B surface antibody following immunisation
- Testing for hepatitis B surface antibody (anti-HBs) routinely is not recommended.
- Testing is recommended for those at risk of occupational exposure (particularly healthcare and laboratory workers):
- Antibody titres should be checked one to four months after the completion of a primary course of vaccine.
- Under the Control of Substances Hazardous to Health (COSHH) Regulations, individual workers have the right to know whether or not they have been protected.
- This information allows appropriate decisions to be made concerning post-exposure prophylaxis (PEP) following known or suspected exposure to the virus.
- Antibody responses to hepatitis B vaccine vary widely between individuals.
- It is preferable to achieve anti-HBs levels above 100 mIU/mL.
- However, levels of 10 mIU/mL or more are generally accepted as enough to protect against infection.
- Responders with anti-HBs levels greater than or equal to 100 mIU/mL do not require any further primary doses. Further assessment of antibody levels is then not indicated. They should then receive the reinforcing booster dose at five years.
- Responders with anti-HBs levels of 10-100 mIU/mL should receive one additional dose of vaccine at that time. Following this, further assessment of antibody levels is not indicated. They should then receive the reinforcing dose at five years.
- An antibody level below 10 mIU/mL is classified as a non-response to vaccine, and testing for markers of current or past infection is good clinical practice. In non-responders, a repeat course of vaccine is recommended, followed by retesting one to four months after the second course. Those who still have anti-HBs levels below 10 mIU/mL, and who have no markers of current or past infection, will require hepatitis B immunoglobulin (HBIG) for protection if exposed to the virus.
- Testing is also recommended in patients with chronic renal failure on dialysis.
- The role of immunological memory in patients with chronic renal failure on renal dialysis does not appear to have been studied, and protection may persist only as long as anti-HBs levels remain above 10 mIU/mL.
- Antibody levels should be monitored annually and if they fall below 10 mIU/mL, a booster dose of vaccine should be given to patients who have previously responded to the vaccine.
- Booster doses should also be offered to any haemodialysis patients who are intending to visit countries with a high endemicity of hepatitis B and who have previously responded to the vaccine, particularly if they are to receive haemodialysis and have not received a booster in the preceding 12 months.
Hepatitis B immunoglobulin
- Specific hepatitis B immunoglobulin (HBIG) provides passive immunity.
- It can give immediate but temporary protection.
- HBIG is given concurrently with hepatitis B vaccine and does not affect the development of active immunity.
- If the infection occurred at the time of immunisation, administration of HBIG may still prevent the development of carrier status.
See separate article Needlestick Injury.
- Post-exposure prophylaxis (PEP) involves giving hepatitis B vaccine and possibly immunoglobulin too if required.
- Immunoglobulin is given at a different site and it does not reduce the immune response to the vaccine.
- If the status of the source is unknown, assume infection.
- PEP may be indicated even if the exposed person has received hepatitis B vaccine previously.
- It should be given within 48 hours and certainly no later than seven days after exposure.
- The incubation period of the disease is 40 to 160 days.
- If the site of exposure is a 'needlestick' injury, cut or abrasion, the site should be washed immediately with soap and water.
- It is indicated for babies born to mothers who are chronic carriers of hepatitis B virus (HBV) or to mothers who have had acute hepatitis B during pregnancy.
Adverse reactions to the vaccine are few and usually mild:
- There may be some soreness and erythema around the site. These are the most common reactions.
- Fatigue, malaise and influenza-like symptoms are rare.
- An association with a Guillain-Barré-type syndrome has not been substantiated.
Hepatitis B immunoglobulin (HBIG) is well tolerated.
Evidence shows that universal vaccination in countries with a high endemic incidence of hepatitis B is beneficial:
- The benefit in countries with a low endemic incidence is much less and the most effective management is selective immunisation of high-risk groups within those countries.
- Accelerated courses are probably best for drug abusers, as they are notoriously difficult to get to complete a course.
- Since 1982, over one billion doses of hepatitis B vaccine have been used worldwide.
- In many countries where 8% to 15% of children used to become chronically infected with hepatitis B virus (HBV), vaccination has reduced the rate of chronic infection to less than 1% among immunised children.
- Even with immunisation it is essential to take all necessary precautions to prevent transmission of the virus.
There is also evidence that the hepatitis B vaccine reduces the risk of developing hepatocellular carcinoma.
Further reading & references
- Management of the viral hepatitides A, B and C; British Association for Sexual Health and HIV (2008)
- Management of chronic hepatitis B, European Association for the Study of the Liver (February 2009)
- Pyrsopoulos NT et al, Hepatitis B, Medscape, Dec 2011
- Huang LM, Lu CY, Chen DS; Hepatitis B virus infection, its sequelae, and prevention by vaccination. Curr Opin Immunol. 2011 Apr;23(2):237-43. Epub 2011 Jan 21.
- Immunisation - The Green Book; Dept of Health
- Hepatitis B antenatal screening and newborn immunisation programme - best practice guidance, Dept of Health (April 2011)
- Policy on the use of passive immunisation with hepatitis B immunoglobulin (HBIG) for infants born to hepatitis B infected mothers, Health Protection Agency (2008)
- Poorolajal J, Mahmoodi M, Majdzadeh R, et al; Long-term protection provided by hepatitis B vaccine and need for booster dose: a Vaccine. 2010 Jan 8;28(3):623-31. Epub 2009 Nov 1.
- Hepatitis B Fact sheet, World Health Organization, August 2008
- Chang MH; Hepatitis B virus and cancer prevention. Recent Results Cancer Res. 2011;188:75-84.
|Original Author: Dr Hayley Willacy||Current Version: Dr Louise Newson||Peer Reviewer: Dr Helen Huins|
|Last Checked: 16/05/2012||Document ID: 962 Version: 7||© EMIS|
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