Summary of ACIP Recommendations for HBV Immunization of Health Care Workers
Hepatitis B has been designated a disease for which immunization is strongly recommended.
Key Points from the ACIP Report
- Any health professional who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated (Table 2).
- Hepatitis B vaccine should always be administered by the intramuscular route in the deltoid muscle with a needle 1-1.5 inches long.
- Among health-care professionals, risks for percutaneous and permucosal exposures to blood vary during the training and working career of each person but are often highest during the professional training period. Therefore, vaccination should be completed during training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions, before trainees have contact with blood.
- In addition, the OSHA Federal Standard requires employers to offer hepatitis B vaccine free of charge to employees who are occupationally exposed to blood or other potentially infectious materials.
- Prevaccination serologic screening for previous infection is not indicated for persons being vaccinated because of occupational risk unless the hospital or health-care organization considers screening cost-effective.
- Postexposure prophylaxis with hepatitis B immune globulin (HBIG) (passive immunization) and/or vaccine (active immunization) should be used when indicated (e.g., after percutaneous or mucous membrane exposure to blood known or suspected to be HBsAg-positive (Table 3).
- Needlestick or other percutaneous exposures of unvaccinated persons should lead to initiation of the hepatitis B vaccine series.
- Postexposure prophylaxis should be considered for any percutaneous, ocular, or mucous membrane exposure to blood in the workplace and is determined by the HBsAg status of the source and the vaccination and vaccine-response status of the exposed person (Table 3).
- If the source of exposure is HBsAg-positive and the exposed person is unvaccinated, HBIG also should be administered as soon as possible after exposure (preferably within 24 hours) and the vaccine series started. The effectiveness of HBIG when administered greater than 7 days after percutaneous or permucosal exposures is unknown.
- If the exposed person had an adequate antibody response (greater than or equal to 10 mIU/mL) documented after vaccination, no testing or treatment is needed, although administration of a booster dose of vaccine can be considered.
- Postvaccination testing for antibody to hepatitis B surface antigen (HBsAb or anti-HBs) response is indicated for HCWs who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks (one to 2 months after completion of the 3-dose vaccination series).
- Persons who do not respond to the primary vaccine series should complete a second three-dose vaccine series or be evaluated to determine if they are HBsAg-positive.
- Revaccinated persons should be retested at the completion of the second vaccine series. Persons who prove to be HBsAg-positive should be counseled accordingly.
- Primary non-responders to vaccination who are HBsAg-negative should be considered susceptible to HBV infection and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood (Table 3).
- Booster doses are not considered necessary. Vaccine-induced antibodies to HBV decline gradually over time, and less than or equal to 60% of persons who initially respond to vaccination will lose detectable antibodies over 12 years. Studies among adults have demonstrated that, despite declining serum levels of antibody, vaccine-induced immunity continues to prevent clinical disease or detectable viremic HBV infection. The possible need for booster doses will be assessed as additional data become available.
- Periodic serologic testing to monitor antibody concentrations after completion of the three-dose series is not recommended. Asymptomatic HBV infections have been detected in vaccinated persons by means of serologic testing for antibody to hepatitis B core antigen (anti-HBc) (1). However, these infections also provide lasting immunity and are not associated with HBV-related chronic liver disease.
|Generic name||Primary schedule and booster(s)||Indications||Major precautions and contraindications||Special considerations|
|Hepatitis B (HB) recombinant vaccine||Two doses IM 4 weeks apart; third dose 5 months after second; booster doses not necessary.||Preexposure: HCWs at risk for exposure to blood or body fluids. Postexposure: See Table 3.||On the basis of limited data, no risk of adverse effects to developing fetuses is apparent. Pregnancy should not be considered a contraindication to vaccination of women. Previous anaphylactic reaction to common baker's yeast is a contraindication to vaccination.||The vaccine produces neither therapeutic nor adverse effects on HBV-infected persons. Prevaccination serologic screening is not indicated for persons being vaccinated because of occupational risk. HCWs who have contact with patients or blood should be tested 1-2 months after vaccination to determine serologic response.|
|Hepatitis B immune globulin (HBIG)||0.06 mL/kg IM as soon as possible after exposure. A second dose of HBIG should be administered 1 month later if the HB vaccine series has not been started.||Postexposure prophylaxis (Table 3): For persons exposed to blood or body fluids containing HBsAg and who are not immune to HBV infection -- 0.06 mL/kg IM as soon as possible (but no later than 7 days after exposure).|
Source: Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee, MMWR, December 26, 1997, Vol. 46(RR-18):1-42.
|Vaccination and antibody response status of exposed person||Treatment when source is|
|HBsAG * positive||HBsAg negative||Source not tested or status unknown|
|Unvaccinated||HBIG + x 1; initiate HB vaccine series &||Initiate HB vaccine series||Initiate HB vaccine series|
|Previously vaccinated: Known responder @||No treatment||No treatment||No treatment|
|Known non-responder||HBIG x 2 or HBIG x 1 and initiate revaccination||No treatment||If known high-risk source, treat as if source were HBsAg positive.|
|Antibody response unknown||Test exposed person for anti-HBs ** 1. If adequate @, no treatment 2. If inadequate @, HBIG x 1 and vaccine booster||No treatment||Test exposed person for anti-HBs. 1. If adequate @, no treatment 2. If inadequate @, initiate revaccination|
* Hepatitis B surface antigen.
+ Hepatitis B immune globulin; dose 0.06 mL/kg intramuscularly.
& Hepatitis B vaccine.
@ Responder is defined as a person with adequate levels of serum antibody to hepatitis B surface antigen (i.e., anti-HBs >= 10 mIU/mL); inadequate response to vaccination defined as serum anti-HBs < 10 mIU/mL.
** Antibody to hepatitis B surface antigen.
Source: Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee, MMWR, December 26, 1997, Vol. 46(RR-18):1-42