Hepatitis B Infections

HB viral infection remains a major vaccine-preventable health hazard for OHCP.^18,19 The virus is transmitted primarily through contact with blood and OPIM (also sexual contact and perinatal exposure).¹⁹ Acute infection is characterized by anorexia, nausea, vomiting, malaise, and fever. After 3 to 10 days, the urine darkens. Jaundice, if present, usually peaks in 1-2 weeks and fades during a 2- to 4-week recovery phase. Following acute infection, up to 10% of those infected become chronic carriers. They may be asymptomatic or develop chronic active hepatitis, cirrhosis, and primary hepatocellular carcinoma.^18,19

Active Immunization: HBV Vaccines^4-6

It is mandated that all OHCP be vaccinated against the HBV. Among OHCP, the risks for percutaneous and permucosal exposures to blood vary during training and work career of each person, but the risks are highest during the professional training period. Therefore, vaccination should be completed during training. Those who decline the hepatitis B vaccination series must sign a copy of the Mandatory Hepatitis B Vaccination Declination Form (Box 3).⁵

Box 3. Mandatory Hepatitis B Vaccination Declination Form⁵

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

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Employee Signature


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Date

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Hepatitis B vaccines (Table 1) contain hepatitis B surface antigen (HBsAg) protein grown in baker’s yeast using recombinant DNA technology. It is subsequently purified and adsorbed to aluminum hydroxide. Primary immunization with hepatitis B vaccine consists of two or three IM doses. The deltoid muscle is the preferred site for adolescent and adult patients because injections given into the buttocks yield lower seroconversion rates.¹⁷

Table 1. HBV Vaccines for Adolescents and Adults.²⁰

Vaccines	Indications	Schedules	Adverse Effects
Engerix-B	Preexposure	3 IM doses at 0, 1, and 6 months	Pain at injection site (most common); fever; anaphylaxis in persons with history of allergic reaction to baker’s yeast.
Recombivax-HB	Preexposure	3 IM doses at 0, 1, and 6 months	Pain at injection site (most common); systemic effect, anaphylaxis in persons with history of allergic reaction to baker’s yeast or latex.
Heplisav-B	Preexposure	2 IM doses at 0 and 1 month	Pain at injection site (most common); fever; anaphylaxis in persons with history of allergic reaction to baker’s yeast.
PreHevbrio	Preexposure	3 IM doses at 0, 1 and 6 months	Pain at injection site (most common), headache, fatigue, myalgia.
Twinrix	Preexposure	3 IM doses at 0, 1 and 6 months OR Accelerated 4 dose schedule of 0, day 7, day 21-30 and booster at 12 months	Pain at injection site (most common), redness, headache, fatigue, anaphylaxis in persons with history of allergic reaction to yeast or neomycin.
Engerix-B	Postexposure	4 IM doses at 0, 1, 2 and 12 months	Pain at injection site (most common); fever; anaphylaxis in persons with history of allergic reaction to baker’s yeast.

While pre-vaccination serologic screening for previous HBV infection is not indicated for persons being vaccinated because of occupational risk, post-vaccination confirmation of seroconversion is strongly recommended 1-2 months after the 3rd dose (Box 4).

Box 4. Post-vaccination Confirmation of Seroconversion^6,21

Post-vaccination confirmation of seroconversion is strongly recommended 1-2 months after the final dose.
1. A HBsAb titer >10 mIU/mL is considered adequate
OHCP who do not develop an adequate antibody response to the primary vaccine series shall undergo a second 2 or 3-dose vaccine series.
1. Retesting for HBsAb is strongly recommended 1-2 months after the 3^rd dose of the second vaccine series.
  1. If no antibody response occurs, testing for HBsAg is strongly recommended.
    1. Those who are HBsAg-negative shall be counseled about precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood.
    2. Those who are HBsAg-positive shall be counseled about how to prevent the transmission of HBV to others and about the need for medical consultation.

It is well-established that over time the HBsAb titer falls, often below the currently accepted threshold value of 10 mIU/mL. However, there is no evidence that vaccinated persons lose their immunity simply because the anti-HBsAb titer drops below the arbitrary threshold. Currently, the U.S. Public Health Service does not recommend routine booster doses of the hepatitis B vaccine.²¹

Passive Immunization: Hepatitis B Immune Globulin^4,6

OHCP who either declined vaccination or failed to seroconvert are at risk of HBV infection. Hepatitis B immune globulin (HBIG), if administered within 1 week of exposure (ideally within 24 hours), is 75% effective in preventing infection. In addition to HBIG prophylaxis, an alternate 4-dose series of the vaccine should also be offered to those who in the past declined the vaccine (see Table 1). If the person chooses not to take the vaccine, a second dose for HBIG should be administered 30 days after the first dose.

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