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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

  1. 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.
  2. CDC. Medical examinations. Atlanta, GA: US Department of Health and Human Services, CDC; 2005. Available at http://www.cdc.gov/ncidod/dq/health.htm.
  3. Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology 2001;34: 1225--41.
  4. Shapiro CN, McCaig LF, Gensheimer KF et al. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 1989;8:870--5.

* Hepatitis B surface antigen prevalence of >8%.

Box A-1

Box A-1
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