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Hepatitis B Immunization in an STD Clinic: Lessons Learned in San Diego County - A Practical Guide This manual is designed to help STD clinics incorporate hepatitis B immunizations into their existing counseling and treatment programs. It contains information on how to get buy-in from key stakeholders, how and what to train clinic staff, patient education, and implementation. San Diego County's experience is provided as an example.



Hepatitis 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 Islanders

  • Household contacts and sex partners of people with chronic HBV infection

  • People who have had a sexually transmitted disease

  • 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

  • Hemodialysis patients

  • Recipients of certain blood products

  • Clients and staff of institutions for the developmentally disabled

  • Inmates in long-term correctional facilities

  • Certain international travelers

  • People with liver disease

  • Hepatitis B vaccination is recommended for all children 0–18 years of age.


Vaccine making inroads against hepatitis B

While heralded as a success story, physicians are urged to stay the current course and to expand the vaccine's use to others at risk.

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 children.

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 group.

"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 price.

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 time."

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, he said.

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.

The recommendations 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 remain unprotected.

"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.


The Hepatitis B vaccine prevents hepatitis B disease and its serious consequences like hepatocellular carcinoma (liver cancer). Therefore, this is the first anti-cancer vaccine.

Safe and Effective

Medical, scientific 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 chronic illnesses.

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 vaccines.

Vaccine Schedule

Printable 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.

Booster Doses

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 disease.

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 anti-HBs testing.

Adverse Events

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 Vaccine

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.

Additional information is available from the manufacturer's package insert and GlaxoSmithKline Vaccines, telephone (800) 366-8900.


CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(no. RR-12).

CDC. 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 1991;40(no. RR-13).

CDC. Health 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

© 2003 California Hepatitis Resource Center