Hepatitis B Update: Vaccination and Follow-up

Hello. I am Sarah Schillie, a medical officer in the Division of Viral Hepatitis at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. I am happy to speak with you as part of the CDC Expert Commentary series on Medscape. Today, I will be discussing new recommendations from the Advisory Committee on Immunization Practices for the prevention of hepatitis B virus infection in the United States.^[1]

Hepatitis B virus is transmitted through percutaneous or mucosal exposure to blood or body fluids and is highly infectious. Among persons infected with hepatitis B during infancy, approximately 80%-90% will develop chronic infection, with a 25% chance of premature death from cirrhosis or liver cancer. In contrast, chronic infection will occur in approximately 5% of persons infected during adulthood. Among infants, transmission most often occurs perinatally during childbirth from an infected mother. Among adults, transmission is most often by injection drug use or sexual exposure. The incidence of hepatitis B in the United States has increased recently, concomitant with the rise in injection drug use.

Hepatitis B vaccination is the mainstay of hepatitis B prevention efforts. All pregnant women should be screened for hepatitis B with a hepatitis B surface antigen (HBsAg) test, even if they have been vaccinated or previously tested. The new recommendations state that all HBsAg-positive pregnant women should be tested for hepatitis B virus DNA to guide the use of maternal antiviral therapy for the prevention of perinatal infection. For infants born to HBsAg-positive mothers, hepatitis B vaccine and hepatitis B immune globulin should be administered within 12 hours of birth. For other medically stable infants weighing at least 2000 g, hepatitis B vaccine is now recommended to be administered within 24 hours of birth. This universal birth dose serves as a safeguard to prevent perinatal transmission among infants born to infected mothers not identified prenatally. A prior recommendation that included permissive language for delaying the birth dose until after hospital discharge for certain infants born to uninfected mothers no longer exists. Because vaccine response is lower among infants with low birth weight, the recommendations are slightly different for infants weighing less than 2000 g.

All infants should complete the three- or four-dose vaccine series. Infants born to HBsAg-positive mothers or mothers whose status remains unknown indefinitely (such as when a mother surrenders an infant shortly after birth) should have postvaccination serologic testing. Postvaccination serologic testing for infants consists of testing for HBsAg and antibody to HBsAg and is performed between 9 and 12 months of age. Those infants who have not responded to vaccination (a negative HBsAg result and an antibody to HBsAg result <10 mIU/mL) should be revaccinated, followed again by postvaccination serologic testing. Revaccination can consist of a single dose of vaccine followed by postvaccination serologic testing, with two more doses of vaccine if necessary, followed again by postvaccination serologic testing. Alternatively, revaccination can consist of a complete second vaccine series (three doses) followed by postvaccination serologic testing. Administration of more than two complete vaccine series is generally not recommended.

Adults at risk for hepatitis B should also be vaccinated. This includes those at risk by sexual exposure (including men who have sex with men) and those at risk by percutaneous exposure (including injection drug users, household contacts of hepatitis B-infected persons, residents and staff at facilities for developmentally disabled persons, healthcare and public safety personnel, end-stage renal disease patients, and persons with diabetes). Other adults recommended for hepatitis B vaccination include travelers to certain areas, incarcerated persons, and persons with HIV. The new recommendations also explicitly state that hepatitis B vaccination is recommended for adults with hepatitis C infection and other chronic liver diseases, including but not limited to cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and liver enzyme levels more than twice the upper limit of normal.

All other persons seeking protection from hepatitis B, even without acknowledgement of a risk factor, should be vaccinated. Postvaccination serologic testing is not routinely recommended following adult vaccination but is recommended for healthcare personnel and public safety workers, hemodialysis patients, HIV-infected and other immune compromised persons, and sex partners of infected persons. Postvaccination serologic testing for adults consists of testing for antibody to HBsAg 1-2 months after completion of the vaccine series. Those with antibody to HBsAg <10 mIU/mL should be revaccinated. For more information, please visit CDC's hepatitis website. Thank you.