HEPATITIS B VACCINATIONS
B Immunization in a STD Clinic: Lessons Learned in San
Diego County - A Practical Guide
Who needs hepatitis B vaccine?
People in the groups listed
below are at moderate or high risk for hepatitis B
virus (HBV) infection and should be vaccinated.
Immigrants/refugees from areas
of high HBV endemicity (Asia, Sub-Saharan Africa,
Amazon Basin, Eastern Europe, Middle East) as well
as children born in the United States to persons
from these areas.
Alaska Natives and Pacific
Household contacts and sex
partners of people with chronic HBV infection
People who have had a sexually
People with more than one sex
partner in six months
Men who have sex with men
Users of illicit injectable
drugs and their sex partners
Health care workers and public
safety workers who have contact with blood
Adopted children from countries
where HBV is endemic
Recipients of certain blood
Clients and staff of
institutions for the developmentally disabled
Inmates in long-term
Certain international travelers
People with liver disease
Hepatitis B vaccination is
recommended for all children 0–18 years of age.
HEALTH & SCIENCE
Vaccine making inroads against
While heralded as a
success story, physicians are urged to stay the current
course and to expand the vaccine's use to others at
By: Susan J. Landers
covers public health, science and related federal policy
issues. (202) 789-7408 (August 5, 2002)
Washington -- The
introduction of the hepatitis B vaccine 20 years ago
marked the decline of that disease and its accompanying
serious health consequences in the United States -- a
major public health achievement, notes the Centers for
Disease Control and Prevention.
Before 1982, an
estimated 200,000 to 300,000 people in the United States
were infected with hepatitis B, including 20,000
Since then, an
extensive campaign that saw the vaccination of about 40
million infants and children and 30 million adults has
resulted in a decline in the number of those infected in
this country to an estimated 79,000 in 2001. In
addition, the disease has been virtually eliminated in
the health profession because of high vaccination rates.
"It's been a
wonderful vaccine and has saved millions of lives and
will save millions more because of the risk posed by the
disease for liver cancer and liver failure," said
Deborah Wexler, MD, executive director and founder of
the Immunization Action Coalition in St. Paul, Minn.
But despite its
successful 20-year run, the vaccine still hasn't reached
many of those at risk of infection by HBV, which is
found in the blood and other body fluids of infected
people. Contact with even a small amount of infected
blood can cause infection.
Young adults and
intravenous drug users are often missed in vaccination
campaigns. A sweep through the nation's prisons could
catch many of those carrying the virus. And by requiring
student vaccinations, colleges could help with that
"On the order of
magnitude of 5% to 6% of Americans are infected with
hepatitis B," said William Schaffner, MD, professor
and chair of the Preventive Medicine Dept. at Vanderbilt
University School of Medicine, Nashville, Tenn.
The first dose of the
three-dose hepatitis B series of shots is generally
administered shortly after birth. Older adolescents and
at-risk adults can start the series at any time.
Many physicians have
expressed concern about patients not returning for shots
two and three once the series has begun, but Dr.
Schaffner encourages them to begin the series anyway.
"One shot is better than none and two shots are
better than one," he said.
The cost for adults,
which is not generally covered by health insurance, also
could be a deterrent to many young adults in their first
jobs or for IV drug users who already live at society's
edge. The shots are about $90 for the series, and the
physician's fee would be in addition to that.
The cost is about that
of "a pair of athletic shoes and a big night on the
town," noted Dr. Shaffner, and is well worth the
A worldwide effort
Infection can result
in serious consequences. While many of those with the
disease are able to fight off the virus, about 10%
remain chronically infected and become carriers. Each
year approximately 5,000 Americans die of liver failure
related to hepatitis B and another 1,500 die of liver
cancer related to hepatitis B.
"Although it is
unheralded in this regard, the hepatitis B vaccine is
really our first anti-cancer vaccine," Dr.
Schaffner said. "This is also our first vaccine
against a sexually transmitted disease. So this is big
There is an
international effort under way using hepatitis B vaccine
to control and substantially reduce the occurrence of
liver cancer around the world, said Dr. Schaffner,
noting that liver cancer is one of the leading cancers
in China and in parts of Africa.
Under the sponsorship
of the World Health Organization, more than 100
countries are now immunizing their children routinely,
Although the vaccine
was first recommended for those at high risk for
infection -- including intravenous drug users, men who
have sex with men and those who have heterosexual
relations with many partners -- it became apparent that
many people were being missed.
In 1991, the CDC's
Advisory Committee on Immunization Practices recommended
universal childhood vaccination to prevent the infection
of newborns from their mothers as well as the
vaccination of high-risk adolescents and adults.
Throughout the 1990s the recommendation was broadened
and now includes all children through age 19.
have been widely adopted and, from 1993 to 2000, the
national coverage rate for hepatitis vaccine among
children 19 to 35 months old increased from 16% to 90%,
while the coverage rate for U.S. adolescents ages 13 to
15 increased from near zero to 67%.
The nation now has a
cohort of vaccinated children to help ensure the defeat
of the disease in time. But adults are still likely to
"Our program from
age 19 on up is much less successful, just as all adult
immunization programs are less successful," Dr.
Shaffner said. "Doctors are often not good at
identifying who's at risk. Patients don't always tell
doctors the whole story."
While the vaccine
advisory committee recommends the vaccine for patients
who have had more than one sexual partner in the last
six months, Dr. Shaffner would broaden that to urge
immunization for all patients who are sexually active
and not monogamous.
The vaccine's wide
acceptance rate for infants and children was not arrived
at without some setbacks. The disease is "silent in
infancy," noted Dr. Wexler, as it doesn't manifest
any clinical symptoms at that time. So physicians and
parents were somewhat reluctant to administer the
vaccine, she said.
The vaccine was also
thought by some to cause such serious diseases as
multiple sclerosis, and its administration to newborns
was halted while thimerosal was removed from it.
The vaccine is now
viewed as safe. "It's an excellent vaccine. I have
given thousands of doses, and I haven't seen an adverse
event from it myself," Dr. Wexler said.
MORE FROM THE CENTERS FOR DISEASE
CONTROL AND PREVENTION:
The Hepatitis B
vaccine prevents hepatitis B disease and its serious
consequences like hepatocellular carcinoma (liver
cancer). Therefore, this is the first anti-cancer
Safe and Effective
and public health communities strongly endorse using
hepatitis B vaccine as a safe and effective way to
prevent disease and death.
Scientific data show
that hepatitis B vaccines are very safe for infants,
children, and adults. There is no confirmed evidence
which indicates that hepatitis B vaccine can cause
To assure a high
standard of safety with vaccines, several federal
agencies continually assess and research possible or
potential health effects that could be associated with
childhood and adult immunization schedules, 2002:
National Immunization Program, CDC
If the vaccination
series is interrupted after the first dose, the second
dose should be administered as soon as possible. The
second and third doses should be separated by an
interval of at least 2 months. If only the third dose is
delayed, it should be administered when convenient.
Current data show that
vaccine-induced hepatitis B surface antibody (anti-HBs)
levels may decline over time; however, immune memory (anamnestic
anti-HBs response) remains intact indefinitely following
immunization. Persons with declining antibody levels are
still protected against clinical illness and chronic
For health care
workers with normal immune status who have demonstrated
an anti-HBs response following vaccination, booster
doses of vaccine are not recommended nor is periodic
Case reports of
unusual illnesses following vaccines are most often
related to other causes and not related to a vaccine.
Whenever large number of vaccines are given, some
adverse events will occur coincidentally after
vaccination and be falsely attributed to the vaccine.
Anyone believing they
have had a possible reaction or adverse health effect
from a vaccine should report it to their health care
provider. The Vaccine Adverse Events Reporting System
(1-800-822-7967) receives reports from health care
providers and others about vaccine side effects.
Combined Hepatitis A and Hepatitis B
On May 11, 2001, the
Food and Drug Administration (FDA) licensed a combined
hepatitis A and B vaccine (Twinrix®) for use in persons
aged >18 years. Twinrix is manufactured and
distributed by GlaxoSmithKline
Indications and Usage
Twinrix is indicated
for vaccination of persons aged >18 years against
hepatitis A and B. Any person in this age group having
an indication for both hepatitis A and B vaccination can
be administered Twinrix, including patients with chronic
liver disease, users of illicit injectable drugs, men
who have sex with men, and persons with clotting factor
disorders who receive therapeutic blood products (1,2).
For international travel, hepatitis A vaccine is
recommended for travelers to areas of high or
intermediate hepatitis A endemicity; hepatitis B vaccine
is recommended for travelers to areas of high or
intermediate hepatitis B endemicity who plan to stay for
>6 months and have frequent close contact with the
local population (3). Primary vaccination consists of
three doses, given on a 0-, 1-, and 6-month schedule,
the same schedule as that used for single antigen
hepatitis B vaccine.
is available from the manufacturer's package insert and
GlaxoSmithKline Vaccines, telephone (800) 366-8900.
Prevention of hepatitis A through active or passive
immunization: recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 1999;48(no.
Hepatitis B virus: a comprehensive strategy for
eliminating transmission in the United States through
universal childhood vaccination: recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR
information for international travel 2001--2002.
Atlanta, Georgia: US Department of Health and Human
Services, Public Health Service, CDC, 2001.
MMWR, September 21,
2001 / 50(37);806-7.
Resource: Centers for
Disease Control and Prevention 2002