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Appendix A
Case Finding and Management of Hepatitis B Surface Antigen
(HBsAg)--Positive Persons During Delivery of Vaccination Services
Chronically infected persons are at high risk for chronic liver disease and are a major reservoir of hepatitis B virus
(HBV) infection. Foreign-born persons, especially persons from Africa, Asia, and the Pacific Islands, have high* rates of chronic
HBV infection. During delivery of recommended hepatitis B vaccination services (e.g., HBsAg screening of pregnant women
and serologic testing to assess susceptibility), vaccination providers will identify persons who are HBsAg positive. These
persons require counseling and medical management for chronic HBV infection to reduce their risk for chronic liver disease.
Their susceptible household, sexual, and needle-sharing contacts also need to be vaccinated against hepatitis B.
Few programs have been implemented to identify HBsAg-positive persons, provide or refer these persons for
appropriate medical management, and provide vaccination to their contacts
(1). Extending these services to persons identified as
HBsAg positive will help prevent serious sequelae in chronically infected persons and enhance vaccination strategies for elimination
of HBV transmission. This Appendix addresses case finding and management of persons with chronic HBV infection in
the context of vaccine delivery. The recommendations are not intended to represent a comprehensive prevention program
for chronically infected persons.
Case Finding in the Context of Vaccination Service Delivery
All foreign-born persons (including immigrants, refugees, asylum seekers, and internationally adopted children) born
in Asia, the Pacific Islands, Africa, and other regions with high endemicity of HBV infection (Box A-1) should be tested
for HBsAg, regardless of vaccination status.
--- For all persons born in high-endemic countries who are applying for permanent U.S. residence, HBsAg screening
and appropriate follow-up on the basis of HBsAg test results should be included as part of the required
overseas premigration and domestic adjustment-of-visa status medical examination process
(2). HBsAg-positive persons should be considered eligible for migration and adjustment-of-visa status and counseled and recommended for
follow-up medical evaluation and management in U.S. resettlement communities.
--- Providers should identify children born in
high-endemic countries and provide HBsAg testing and follow-up in
all settings that provide health care. Retesting of persons who were tested for HBsAg in other countries should
be considered.
Other persons who should be tested for HBsAg as part of vaccination services include
--- all pregnant women (See Prevention of Perinatal HBV Infection and Management of Pregnant Women),
--- persons who receive prevaccination testing for susceptibility and who test positive for anti-HBc (See
Prevaccination Testing for Susceptibility),
--- hemodialysis patients, and
--- nonresponders to vaccination (See Appendix B, Postvaccination Testing for Serologic Response).
Management of Persons Identified as HBsAg Positive
All persons with HBsAg-positive laboratory results should be reported to the state or local health department.
To verify the presence of chronic HBV infection, HBsAg-positive persons should be retested. The absence
of immunoglobulin M antibody to HBcAg or the persistence of HBsAg for 6 months indicates chronic HBV infection.
Persons with chronic HBV infection should be referred for evaluation by a physician experienced in the management
of chronic liver disease (3). Certain patients with chronic hepatitis B will benefit from early intervention with
antiviral treatment or screening to detect hepatocellular carcinoma at an early stage.
Household, sexual, and needle-sharing contacts of chronically infected persons should be identified. Unvaccinated
sex partners and household and needle-sharing contacts should be tested for susceptibility to HBV infection
(see Prevaccination Serologic Testing for Susceptibility) and should receive the first dose of hepatitis B vaccine
immediately after collection of the blood sample for serologic testing. Susceptible persons should complete the vaccine series using
an age-appropriate vaccine dose and schedule (see Tables 2 and 6) Persons who are not fully vaccinated should complete
the vaccine series.
Sex partners of HBsAg-positive persons should be counseled to use methods (e.g., condoms) to protect themselves
from sexual exposure to infectious body fluids (e.g., semen or vaginal secretions) unless they have been demonstrated to
be immune after vaccination (i.e., anti-HBs
>10 mIU/mL) or previously infected (anti-HBc positive).
To prevent or reduce the risk for transmission to others, HBsAg-positive persons should be advised concerning the
risks for
--- perinatal transmission to infants born to
HBsAg-positive women and the need for such infants to
receive hepatitis B vaccine and HBIG beginning at birth (see Prevention of Perinatal HBV Infection and Management of Pregnant Women) and
--- transmission to household, sexual, and needle-sharing contacts and the need for such contacts to receive hepatitis
B vaccine.
HBsAg-positive persons should also be advised to
--- use methods (e.g., condoms) to protect nonimmune sex partners from acquiring HBV infection from sexual
activity until the sex partners can be vaccinated and immunity documented;
--- cover cuts and skin lesions to prevent the spread of infectious secretions or blood;
--- refrain from donating blood, plasma, tissue, or semen (organs may be donated to HBV-immune or chronically
infected persons needing a transplant); and
--- refrain from sharing household articles (e.g., toothbrushes, razors, or personal injection equipment) that could
become contaminated with blood.
To protect the liver from further harm, HBsAg-positive persons should be advised to
--- avoid or limit alcohol consumption because of the
effects of alcohol on the liver;
--- refrain from beginning to take any new medicines, including over-the-counter and herbal medicines,
without consulting their health-care provider; and
--- obtain vaccination against hepatitis A if chronic liver disease is found to be present.
When seeking medical or dental care, HBsAg-positive persons should be advised to inform those responsible for their
care of their HBsAg status so they can be evaluated and their care managed appropriately.
Other counseling messages:
--- HBV is not spread by breastfeeding, kissing, hugging, coughing, ingesting food or water, sharing eating utensils
or drinking glasses, or casual contact.
--- Persons should not be excluded from school, play, child care, work, or other settings on the basis of their HBsAg
status unless they are prone to biting (4).
--- Involvement with a support group might help patients cope with chronic HBV infection.
References
Weinberg MS, Gunn RA, Mast EE, Gresham L, Ginsberg M. Preventing transmission of hepatitis B virus from people with chronic infection. Am
J Prev Med 2001;20:272--6.
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