There are two components to preventing hepatitis B:

1. Prevention of transmission of the virus
2. Immunisation

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.

Exposure to HBV can produce a variety of different states:¹

• 60-65% show subclinical disease and recover fully
• 20-25% develop acute hepatitis
• 5-10% become 'healthy' carriers, i.e. HBsAg positive after 6 months
• 5-10% develop chronic hepatitis
• Those that carry the antigen HBsAg are not at high risk of transmitting the disease, unless they also carry the antigen HBeAg.
• Carriers of HBeAg are very infectious

Epidemiology

See Hepatitis B article.

Prevention of transmission

Immunisation

Hepatitis B vaccine is safe and effective, but should not be seen as an alternative to a strategy of prevention of transmission.

Immunisation schedule

• The standard course of immunisation involves 3 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 can have a schedule of 0,7 and 21 days. The vaccine is administered intramuscularly, usually into the deltoid muscle.³ After an accelerated course, a booster at 1 year is recommended. It can be used in those who are immunocompromised, as with HIV infection, but a higher dose may be required or extra booster injections.

The vaccine should be given into the deltoid region or anterior thigh in babies.
It is less effective if given into the buttock.
It is quite possible that a course may give lifelong immunity,⁴ but for health professionals one further booster at 5 years is recommended.
Antibody titres should be tested in health professionals 2 to 4 months after the primary course.

• A titre above 100 mIU/ml is regarded as adequate.
• Around 10-15% of adults fail to respond to three doses of vaccine or respond poorly.¹
• Poor responders with titres of 10 to 100 mIU/ml should have a booster and those with a titre below 10 mIU/ml should repeat the course.
• Those over 40 years old, who are obese or who smoke are more likely to fail to respond.
• Alcoholics are also reported as having lower seroconversion rates, particularly those with advanced liver disease.
• Patients who are immunosuppressed or on renal dialysis may also respond less well and require larger or more doses of vaccine.
• Failure to produce any antibody after 2 complete courses should not be seen as necessarily meaning no immunity, as immunity to the disease is largely cell-mediated rather than by antibody.

Post-exposure management

See Needlestick Injury article.

• 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 7 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 or to mothers who have had acute hepatitis B during pregnancy.
More details about PEP can be found in 'The Olive Book', and 'Guidance for Clinical Healthcare Workers' from the DH's hepatitis B resources.^2,5

Complications

Adverse reactions to the vaccine are few and usually mild:

• There may be some soreness and erythema around the site.
• Fatigue, malaise and influenza-like symptoms are rarer.
• An association with a Guillain-Barré-type syndrome has not been substantiated.

Effective practice

Evidence shows that universal vaccination in countries with a high endemic incidence of hepatitis B is beneficial:⁶

• 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.
• Even with immunisation it is essential to take all necessary precautions to prevent transmission of the virus.

Document references

1. Deptartment of Health; Immunisation against infectious disease - 'The Green Book' (various dates)
2. Guidance for Health Care Workers; Prevention of Blood Borne infections (Hep B and HIV).
3. Nothdurft HD, Dietrich M, Zuckerman JN, et al; A new accelerated vaccination schedule for rapid protection against hepatitis A and B. Vaccine. 2002 Jan 15;20(7-8):1157-62. [abstract]
4. No authors listed; Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity. Lancet. 2000 Feb 12;355(9203):561-5. [abstract]
5. Hepatitis B key documents, Department of Health (UK)
6. Norris S. Mohsen A; Hepatitis B Prevention. Clinical Evidence (2005).

Internet and further reading

• Hepatitis B key documents, Department of Health (UK)
• Guidance for Health Care Workers; Prevention of Blood Borne infections (Hep B and HIV).
• Management of the Viral Hepatitides A, B and C, British Association for Sexual Health & HIV (2008)
• NHS Immunisation Website; Patient information
• Pyrsopoulos NT, Reddy KR; Hepatitis B. eMedicine. June 2009.
• Management of chronic hepatitis B, European Association for the Study of the Liver (February 2009)

Acknowledgements