Hepatitis B Questions and Answers for Health Professionals
Index of Questions
- How is HBV transmitted?
- How long does HBV survive outside the body?
- What should be used to remove HBV from environmental surfaces?
- Who is at risk for HBV infection?
- Who should be screened for HBV?
- Are international travelers at risk for HBV infection?
- What are the signs and symptoms of HBV infection?
- What is the incubation period for hepatitis B?
- When symptoms of acute hepatitis B occur, how long do they usually last?
- How serious is acute HBV infection?
- How serious is chronic HBV infection?
- How likely is HBV infection to become chronic?
- How is HBV infection treated?
- What is HBV reactivation?
- Who is at greatest risk for HBV reactivation?
- Are patients undergoing treatment for HCV at risk for HBV reactivation?
- Who should be vaccinated against hepatitis B?
- Is hepatitis B vaccination recommended in certain settings?
- What are the hepatitis B vaccines licensed for use in the United States?
- What are the recommended schedules for hepatitis B vaccination?
- What are the recommended dosages of hepatitis B vaccines?
- Who should not receive hepatitis B vaccine?
- Can a patient receive the first dose of hepatitis B vaccine from one manufacturer and subsequent doses from another manufacturer?
- If there is an interruption between doses of hepatitis B vaccine, does the vaccine series need to be restarted?
- Is it harmful to administer an extra dose(s) of Hepatitis A or hepatitis B vaccine or to repeat the entire vaccine series if documentation of vaccination history is unavailable?
- Can hepatitis B vaccine be administered concurrently with other vaccines?
- How long does protection from hepatitis B vaccine last?
- Why should an infant receive hepatitis B vaccine at birth, even if the mother is negative for hepatitis B surface antigen (HBsAg)?
- Should pregnant women be tested for HBV?
- Can hepatitis B vaccine be given during pregnancy or lactation?
- Can hepatitis B vaccine be given to immunocompromised people, such as people on hemodialysis or people with HIV?
- Can hepatitis B vaccine be given after exposure to HBV?
- Should people be tested for immunity to hepatitis B before being vaccinated?
- Is there any benefit or risk in vaccinating a person who has been infected with HBV?
- Who should receive postvaccination testing?
- When should postvaccination testing be done in infants born to HBsAg-positive mothers?
- Can anti-HBs levels following vaccination decline over time?
- Are booster doses of hepatitis B vaccine recommended?
Overview and Statistics
What are the case definitions for reportable hepatitis B virus (HBV) infections?
Case definitions have been developed by CDC, in collaboration with the Council of State and Territorial Epidemiologists, to provide uniform clinical and laboratory-testing criteria for the identification and reporting of nationally notifiable infectious diseases. The case definitions for acute, chronic, and perinatal hepatitis B are available at the following links:
- Acute hepatitis B
- Chronic hepatitis B
- Perinatal hepatitis B (Acquired in the United States or U.S. Territories)
- Additional guidance on viral hepatitis surveillance and case management is available.
How many new HBV infections occur annually in the United States?
In 2017, a total of 3,407 cases of acute hepatitis B were reported to CDC (1). The overall incidence rate for 2016 was 1.0 cases per 100,000 population. After adjusting for under-ascertainment and under-reporting, an estimated 22,100 acute hepatitis B cases occurred in 2017 (1).
Has the rate of new HBV infections in the United States changed?
The number of reported acute hepatitis B cases has remained stable with a slight increase in 2017 (1). The trend is influenced by improved immunization, increasing injection drug use related to the opioid crisis (2), and improved surveillance.
Figure 3.1. Actual number of acute hepatitis B cases submitted to CDC by states and estimated* number of acute hepatitis B cases — United States, 2010–2017.
Source: CDC, National Notifiable Diseases Surveillance System.
How common is chronic HBV infection in the United States?
In 2016, the number of people living with HBV infection was 862,000 (3).
Transmission, Symptoms, and Treatment
How is HBV transmitted?
HBV is transmitted through activities that involve percutaneous (i.e., puncture through the skin) or mucosal contact with infectious blood or body fluids (e.g., semen and saliva), including
- sex with an infected partner;
- injection drug use that involves sharing needles, syringes, or drug-preparation equipment;
- birth to an infected mother;
- contact with blood from or open sores of an infected person;
- needle sticks or sharp instrument exposures; and
- sharing items (e.g., razors and toothbrushes) with an infected person.
HBV is not spread through food or water, sharing eating utensils, breastfeeding, hugging, kissing, hand holding, coughing, or sneezing.
How long does HBV survive outside the body?
HBV can survive outside the body at least 7 days and still be capable of causing infection (5).
What should be used to remove HBV from environmental surfaces?
Any blood spills (including dried blood, which can still be infectious) should be disinfected using a 1:10 dilution of one part household bleach to 10 parts of water. Gloves should be worn when cleaning up any blood spills.
Who is at risk for HBV infection?
The following populations are at increased risk for becoming infected with HBV:
- infants born to infected mothers,
- sex partners of infected persons,
- men who have sex with men,
- injection-drug users;
- household contacts or sexual partners of known persons with chronic HBV infection;
- health care and public safety workers at risk for occupational exposure to blood or blood-contaminated body fluids, and
- hemodialysis patients.
Who should be screened for HBV?
Screening should include testing for three HBV screening seromarkers (HBsAg, antibody to HBsAg [anti-HBs], and antibody to hepatitis B core antigen [anti-HBc]) so that persons can be classified into the appropriate hepatitis B category and properly recommended to receive vaccination, counseling, and linkage to care and treatment (6).
- People born in countries with 2% or higher HBV prevalence
- Men who have sex with men
- People who inject drugs
- HIV-positive persons
- Household and sexual contacts of HBV-infected persons
- People requiring immunosuppressive therapy
- People with end-stage renal disease (including hemodialysis patients)
- Blood and tissue donors
- People with elevated alanine aminotransferase levels (>19 IU/L for women and >30 IU/L for men)
- Pregnant women (HBsAg only is recommended)
- Infants born to HBV-infected mothers (HBsAg and anti-HBs are only recommended)
Are international travelers at risk for HBV infection?
The risk for HBV infection in international travelers is generally low, except for certain travelers to regions where the prevalence of chronic HBV infection is high or intermediate (i.e., hepatitis B surface antigen prevalence of ≥2%). Hepatitis B vaccination should be administered to unvaccinated people traveling to those countries.
More information about hepatitis B and travel is available from CDC’s Travelers’ Health site.
What are the signs and symptoms of HBV infection?
Newly acquired (acute) HBV infections only cause symptoms some of the time. The presence of signs and symptoms varies by age. Most children under age 5 years and newly infected immunosuppressed adults are generally asymptomatic, whereas 30%–50% of people aged ≥5 years have signs and symptoms (10). When present, signs and symptoms of acute HBV infections can include
- loss of appetite,
- abdominal pain,
- dark urine,
- clay-colored bowel movements,
- joint pain, and
Some acute HBV infections will resolve on their own, but some will develop into chronic infection. Most people with chronic HBV infection are asymptomatic and have no evidence of liver disease. However, some people may develop chronic hepatitis (elevation of AST/ALT), cirrhosis, or hepatocellular carcinoma (a type of liver cancer).
What is the incubation period for hepatitis B?
When symptoms of acute hepatitis B occur, how long do they usually last?
How serious is acute HBV infection?
Acute infection ranges from asymptomatic or mild disease to — rarely — fulminant hepatitis. Disease is more severe among adults aged >60 years. (1).
How serious is chronic HBV infection?
Approximately 25% of people who become chronically infected during childhood and 15% of those who become chronically infected after childhood die prematurely from cirrhosis or liver cancer, and the majority remain asymptomatic until onset of cirrhosis or end-stage liver disease (13, 14).
How likely is HBV infection to become chronic?
The risk for chronic infection varies according to the age at infection and is greatest among young children. Approximately 90% of infants and 25%–50% of children aged 1–5 years will remain chronically infected with HBV. By contrast, approximately 95% of adults recover completely from HBV infection and do not become chronically infected (10).
How is HBV infection treated?
For acute infection, no medication is available; treatment is supportive.
For chronic infection, several antiviral medications are availabe (16). People with chronic hepatitis B infection require linkage to care with regular monitoring to prevent liver damage and/or hepatocellular carcinoma. The American Association for the Study of Liver Diseases (AASLD) practice guidelines for the treatment of chronic hepatitis Bexternal icon has published practice guidelines for the treatment of chronic hepatitis B.
What is HBV reactivation?
HBV reactivation is the abrupt reappearance or rise in HBV DNA in a patient with previously inactive or resolved hepatitis B. It is often accompanied by a flare in disease activity with elevation of liver enzymes with or without symptoms, and can be severe, resulting in death (17).
Who is at greatest risk for HBV reactivation?
Patients at highest risk for HBV reactivation:
- Patients undergoing cancer chemotherapy
- Patients taking immunosuppressive therapy,including
- Rituximab and other drugs which target B lymphocytes (black box warning)
- High-dose steroids
- Anti-TNF agent
- Patients with HIV infection who have discontinued HBV active antiviral drugs
- Patients undergoing solid organ or bone marrow transplantation
- Patients coinfected with HCV
HBV also can reactivate spontaneously.
For more information on risk, monitoring, and prevention of HBV reactivation please see the American Gastroenterological Association’s Institute Guideline on the Prevention and Treatment of Hepatitis B Virus Reactivation During Immunosuppressive Drug Therapyexternal icon and AGA Institute Guidelines on Hepatitis B Reactivation (HBVr): Clinical Decision Support Toolexternal icon. Similar guidance from the European Association for the Study of Liver Disease (EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. Journal of Hepatology 2017; 67:370–398.)
Are patients undergoing treatment for HCV at risk for HBV reactivation?
Because of recent reports of HBV reactivation in HCV co-infected patients receiving direct acting antiviral (DAA) therapy for HCV, all patients initiating HCV DAA therapy should be tested for HBV with HBsAg, anti-HBs, and anti-HBc. People testing positive for HBsAg and/or anti-HBc should be monitored while receiving HCV treatment. More information about treating HBV/HCV co-infected patients can be found on http://hcvguidelines.org/external icon and https://www.aasld.org/publications/practice-guidelines-0external icon.
Hepatitis B Serology
Where can I learn in detail about HBV serology?
CDC offers an online training that covers hepatitis B serology.
What do the different hepatitis B serologic markers mean?
- Hepatitis B surface antigen (HBsAg): The presence of HBsAg, a protein on the surface of HBV, indicates that the person is infectious. It can be detected in high levels in serum during acute or chronic HBV infection. The body normally produces antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine.
- Hepatitis B surface antibody (anti-HBs): The presence of anti-HBs is generally interpreted as indicating recovery and immunity from HBV infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.
- Total hepatitis B core antibody (anti-HBc): Appears at the onset of symptoms in acute hepatitis B and persists for life. The presence of anti-HBc indicates previous or ongoing infection with HBV in an undefined time frame.
- IgM antibody to hepatitis B core antigen (IgM anti-HBc): Positivity indicates recent infection with HBV (≤6 months). Its presence indicates acute infection.
- Hepatitis B e antigen (HBeAg): The presence of HBeAg indicates that the virus is replicating and the infected person has high levels of HBV. HBeAg is a secreted product of the nucleocapsid gene of HBV that is found in serum during acute and chronic hepatitis B.
- Hepatitis B e antibody (HBeAb or anti-HBe): Spontaneous conversion from e antigen to e antibody (a change known as seroconversion) is a predictor of long-term clearance of HBV in patients undergoing antiviral therapy and indicates lower levels of HBV. HBeAb is produced by the immune system temporarily during acute HBV infection or consistently during or after a burst in viral replication.
- HBV DNA: HBV DNA concentration correlates with levels of HBV virus particles. HBV DNA is measured as IU/mL or copies/ml by the polymerase chain reaction assay. HBV viral DNA can be detected and quantified in serum. Several commercial assays can detect and quantify HBV DNA, some to limits as low as 10 IU/ml.
How do I interpret hepatitis B serologic test results?
The following table provides interpretations for different combinations and results of hepatitis B serologic markers.
Antibody and Antigen Biomarkers for Hepatitis B Infection (6)
|Clinical state||HBsAg||Total Anti-HBs||Total anti-HBc||Action|
|Chronic infection||Positive||Negative||Positive||Link to hepatitis B-directed care|
|Link to hepatitis B-directed care|
|Resolved infection||Negative||Positive||Positive||Counseling, reassurance|
(never infected and no evidence of immunization)
|*Isolated core antibody||Negative||Negative||Positive||Depends on situation|
*Isolated core antibody can be a result of:
- False positive: repeat testing required
- Past infection: no action needed
- Occult HBV infection: needs to be known if patient ever becomes immunosuppressed or given chemotherapy or treated with antiviral therapy for hepatitis C virus infection; consider monitoring HBV DNA.
- Passive transfer to infant born to HBsAg-positive mother: no action needed.
How long does it take for blood to test HBsAg-positive after exposure to HBV?
HBsAg will be detected in an infected person’s blood an average of 4 weeks (range: 1–9 weeks) after exposure to the virus. About 1 of 2 patients will no longer be infectious by 7 weeks after onset of symptoms, and all patients who do not remain chronically infected will be HBsAg-negative by 15 weeks after onset of symptoms (12).
Hepatitis B Vaccination
Who should be vaccinated against hepatitis B?
The Advisory Committee on Immunization Practices (ACIP) recommends that the following people receive hepatitis B vaccination:
- All infants
- Unvaccinated children aged <19 years
- People at risk for infection by sexual exposure
- Sex partners of hepatitis B surface antigen (HBsAg)–positive people
- Sexually active people who are not in a long-term, mutually monogamous relationship (e.g., people with more than one sex partner during the previous 6 months)
- People seeking evaluation or treatment for a sexually transmitted infection
- Men who have sex with men
- People at risk for infection by percutaneous or mucosal exposure to blood
- Current or recent injection-drug users
- Household contacts of people who are HBsAg-positive
- Residents and staff of facilities for developmentally disabled people
- Health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids
- Hemodialysis patients and predialysis, peritoneal dialysis, and home dialysis patients
- People with diabetes aged 19–59 years; people with diabetes aged ≥60 years at the discretion of the treating clinician
- International travelers to countries with high or intermediate levels of endemic hepatitis B virus (HBV) infection (HBsAg prevalence of ≥2%)
- People with hepatitis C virus infection
- People with chronic liver disease (including, but not limited to, people with cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
- People with HIV
- People who are incarcerated
- All other people seeking protection from HBV infection
Is hepatitis B vaccination recommended in certain settings?
Yes. In certain health care, evaluation, or treatment settings, a high proportion of clients have known risk factors for HBV infection. ACIP recommends universal vaccination of adults who receive care in those settings, including:
- sexually transmitted disease treatment facilities,
- HIV testing and treatment facilities,
- facilities providing drug-abuse treatment and prevention services,
- health care settings targeting services to injection drug users,
- correctional facilities,
- health care settings targeting services to men who have sex with men,
- chronic hemodialysis facilities and end-stage renal disease programs, and
- institutions and nonresidential day care facilities for people with developmental disabilities.
What are the hepatitis B vaccines licensed for use in the United States?
Three single-antigen vaccines and two combination vaccines are currently licensed in the United States.
Single-antigen hepatitis B vaccines
- RECOMBIVAX HB®
- PEDIARIX®: Combined hepatitis B, diphtheria, tetanus, acellular pertussis (DTaP), and inactivated poliovirus (IPV) vaccine. Cannot be administered before age 6 weeks or after age 7 years.
- TWINRIX®: Combined Hepatitis A and hepatitis B vaccine. Recommended for people aged ≥18 years who are at increased risk for both HAV and HBV infections.
What are the recommended schedules for hepatitis B vaccination?
The vaccination schedule most often used for children and adults is three intramuscular injections, the second and third doses administered at 1 and 6 months, respectively, after the first dose. Alternate schedules have been approved for certain vaccines and/or populations. A new formulation, Heplisav-B (HepB-CpG), manufactured by Dynavax, is approved for two doses 1 month apart.
What are the recommended doses of hepatitis B vaccines?
|Age Group||Single-antigen vaccine||Combination vaccine|
Infants (<1 yr)
Children (1–10 yrs)
Adults (≥18 yrs)
Adults (≥20 yrs)
and other immuno-
§ Combined Hepatitis A and hepatitis B vaccine. This vaccine is recommended for people aged ≥18 years who are at increased risk for both hepatitis B virus and Hepatitis A virus infections.
¶ Recombinant hepatitis B surface antigen protein dose.
** Not applicable.
†† Adult formulation administered on a 2-dose schedule.
§§ Higher doses might be more immunogenic, but no specific recommendations have been made.
¶¶ Dialysis formulation administered on a 3-dose schedule at 0, 1, and 6 months.
*** Two 1.0-mL doses administered at one site, on a 4-dose schedule at 0, 1, 2, and 6 months.
Who should not receive hepatitis B vaccine?
Anyone who has had a serious allergic reaction to a prior dose of hepatitis B vaccine, a component of the hepatitis B vaccine, or yeast should not receive hepatitis B vaccine. When hepatitis B vaccine is administered as part of a combination vaccine, contraindications to other vaccines should be checked.
Can a patient receive the first dose of hepatitis B vaccine from one manufacturer and subsequent doses from another manufacturer?
Yes, but when feasible, the same manufacturer’s vaccines should be used to complete the series. However, vaccination should not be deferred when the manufacturer of the previously administered vaccine is unknown or when the vaccine from the same manufacturer is unavailable.
Data are limited on the safety and immunogenicity effects when HepB-CpG is interchanged with HepB vaccines from other manufacturers. The 2-dose HepB vaccine series only applies when both doses in the series consist of HepB-CpG. Series consisting of a combination of 1 dose of HepB-CpG and a vaccine from a different manufacturer should consist of 3 total vaccine doses and should adhere to the 3-dose schedule minimum intervals of 4 weeks between dose 1 and 2, 8 weeks between dose 2 and 3, and 16 weeks between dose 1 and 3. Doses administered at less than the minimum interval should be repeated. However, a series containing 2 doses of HepB-CpG administered at least 4 weeks apart is valid, even if the patient received another dose from another manufacturer. (18)
If there is an interruption between doses of hepatitis B vaccine, does the vaccine series need to be restarted?
No. The series does not need to be restarted but the following should be considered:
- If the vaccine series was 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 8 weeks.
- If only the third dose is delayed, it should be administered as soon as possible.
Is it harmful to administer an extra dose(s) of hepatitis B vaccine or to repeat the entire vaccine series if documentation of vaccination history is unavailable?
No. If necessary, administering extra doses of single-antigen hepatitis B vaccine is not harmful.
Can hepatitis B vaccine be administered concurrently with other vaccines?
Yes. There is no evidence of interference with the antibody response when hepatitis B vaccine has been administered at the same time as other vaccines. Separate body sites and syringes should be used for simultaneous administration of injectable vaccines.
How long does protection from hepatitis B vaccine last?
Studies indicate that immunologic memory remains intact for at least 30 years among healthy people who initiated hepatitis B vaccination at >6 months of age. The vaccine confers long-term protection against clinical illness and chronic hepatitis B virus infection. Cellular immunity appears to persist even though antibody levels might become low or decline below detectable levels. Among vaccinated cohorts who initiated hepatitis B vaccination at birth, long-term follow-up studies are ongoing to determine the duration of vaccine-induced immunity (19).
Why should an infant receive hepatitis B vaccine at birth before hospital discharge, even if the mother is negative for hepatitis B surface antigen (HBsAg)?
The Advisory Committee on Immunization Practices recommends that all infants receive hepatitis B vaccine at birth, regardless of the infection status of the mother. Infants born to HBV-infected mothers require hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth to protect them from infection. However, because errors or delays in testing, reporting, and documenting maternal HBsAg status can and do occur, administering the first dose of hepatitis B vaccine soon after birth to all infants acts as a safety net, reducing the risk for perinatal infection when maternal HBsAg status is either unknown or incorrectly documented at delivery. Also, initiating the hepatitis B vaccine series at birth has been shown to increase a child’s likelihood of completing the vaccine series on schedule.
Should pregnant women be tested for HBV?
Yes. Women should receive HBsAg testing during each pregnancy, and those who are HBsAg-positive should have HBV DNA testing. AASLD (https://www.aasld.org/publications/practice-guidelines-0external icon) suggests antiviral therapy should be given to pregnant women testing HBsAg-positive to reduce perinatal HBV transmission when maternal HBV DNA is >200,000 IU/ML (20).
Can hepatitis B vaccine be given during pregnancy or lactation?
Yes. The hepatitis B vaccine contains no live virus, so neither pregnancy nor lactation should be considered a contraindication to vaccination of women. On the basis of limited experience, there is no apparent risk of adverse effects to developing fetuses when hepatitis B vaccine is administered to pregnant women. Meanwhile, new HBV infection in a pregnant woman might result in severe disease for the mother and chronic infection for the newborn. Pregnant women who are identified as being at risk for HBV infection during pregnancy should be vaccinated and counseled concerning other methods to prevent HBV infection. Pregnant women may be at increased risk for hepatitis B if they
- have had more than one sex partner during the previous 6 months,
- are being evaluated or treated for a sexually transmitted infection,
- have had recent or current injection-drug use, or
- have had a HBsAg-positive sex partner.
Can hepatitis B vaccine be given to immunocompromised people, such as peopleon hemodialysis or people with HIV?
Yes. Although a larger vaccine dose is required to induce protective antibody in hemodialysis patients. Larger doses or additional doses might also be necessary for other immunocompromised people. Serologic testing of hemodialysis patients and other immunocompromised people is recommended 1–2 months after administration of the final dose of the primary vaccine series to determine the need for revaccination. Detailed guidance on vaccination of hemodialysis patients and other immunocompromised people is available from the Advisory Committee on Immunization Practices recommendations on adult hepatitis B vaccination pdf icon[40 pages].
Can hepatitis B vaccine be given after exposure to HBV?
Yes. After a person has been exposed to HBV, appropriate prophylaxis, given as soon as possible but preferably within 24 hours, can effectively prevent infection. The mainstay of postexposure immunoprophylaxis is hepatitis B vaccine, but, in certain circumstances, the addition of HBIG will provide increased protection (21, 22).
Should people be tested for immunity to hepatitis B before being vaccinated?
Adult populations with risk factors for HBV transmission or at risk for HBV reactivation should receive complete serologic testing (HBsAg, anti-HBs, and anti-HBc) so they can be appropriately counseled, vaccinated, and/or linked to care and treatment. (See section “Who should be screened for HBV?” for persons who should receive pre-vaccination testing).
The first vaccine dose should be administered immediately after collection of the blood sample for serologic testing. Vaccinating of people who are immune to HBV infection because of current or previous infection or vaccination is not harmful and does not increase the risk for adverse events.
For people determined to be HBsAg negative, no further action is required. People with positive HBsAg should be referred to a specialist in the management of hepatitis B infection and receive further serologic evaluation, prevention counseling, and evaluation for antiviral treatment (see Management of HBsAg-Positive Persons). People who are anti-HBc positive should be counseled about their prior exposure to HBV and potential risk for HBV reactivation.
Is there any benefit or risk in vaccinating a person who has been infected with HBV?
People who have already been infected with HBV will receive no benefit from vaccination. However, there is no risk to a previously infected person who receives vaccination.
Who should receive postvaccination testing?
Testing for immunity is advised only for people whose subsequent clinical management depends on knowledge of their immune status, including
- infants born to HBsAg-positive mothers; https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6439a6.htm
- health-care workers and public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids; https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm
- chronic hemodialysis patients, people with HIV, other immunocompromised people (e.g., hematopoietic stem-cell transplant recipients or persons receiving chemotherapy); and
- sex partners of people with chronic HBV infection.
When should postvaccination testing be done in infants born to HBsAg-positive mothers?
For infants born to HBsAg-positive mothers, postvaccination testing should be performed 1–2 months after completion of ≥3 doses of a licensed hepatitis B vaccine series. Testing should not be performed before age 9 months in order to avoid detection of anti-HBs from hepatitis B immune globulin (HBIG) administered during infancy and to avoid detection of HBsAg from vaccine (HBsAg can be transiently positive for 1–18 days after vaccination). Testing at 9 months or later also maximizes detection of late HBV infection. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6439a6.htm
Can anti-HBs levels following vaccination decline over time?
Yes. Following vaccination, anti-HBs levels decline over time. Anti-HBs ≥10 mIU/mL is considered a correlate of vaccine-induced protection for people who have completed an approved vaccination series. Immunocompetent people who achieve an anti-HBs level ≥10 mIU/mL 1–2 months after completing the hepatitis B vaccine series remain protected, even if anti-HBs levels decline to <10 mIU/mL beyond that time (presumably because of persistent cellular immunity). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm
Are booster doses of hepatitis B vaccine recommended?
Booster doses of hepatitis B vaccine are recommended only in certain circumstances.
- Hemodialysis patients: If annual testing for antibody to hepatitis B surface antigen (anti-HBs) shows a decline to <10 mlU/mL, a booster dose should be administered.
- Other immunocompromised people, including people with HIV, hematopoietic stem-cell transplant recipients, and people receiving chemotherapy: The need for booster doses has not been determined. When anti-HBs levels decline to <10 mIU/mL, annual anti-HBs testing and booster doses should be considered for those with an ongoing risk for exposure. People with normal immune status who have been vaccinated, booster doses are not recommended (19, 23).
- Centers for Disease Control and Prevention. Viral Hepatitis Surveillance—United States, 2017. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2019. Available at: https://www.cdc.gov/hepatitis/statistics/2017surveillance/index.htm.
- Gomes, T., et al., The Burden of Opioid-Related Mortality in the United States. JAMA Netw Open, 2018. 1(2): p. e180217. Available from PubMed Central PMC6324425external icon
- Patel EU, Thio CL, Boon D, Thomas DL, Tobian AA. Prevalence of hepatitis B and hepatitis D virus infections in the United States, 2011-2016external icon. Clin Infect Dis. 2019 Jan 3.
- Kowdley KV, Wang CC, Welch S, Roberts H, Brosgart CL. Prevalence of chronic hepatitis B among foreign-born persons living in the United States by country of origin. Hepatology 2012;56(2):422-33.
- Bond WW, Favero MS, Petersen NJ, Gravelle CR, Ebert JW, Maynard JE. Survival of hepatitis B virus after drying and storage for one week. Lancet. 1981;1(8219):550-1.
- Abara WE, Qaseem A, Schillie S, McMahon BJ, Harris AM, High Value Care Task Force of the American College of P, et al. Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2017;167(11):794-804.
- LeFevre ML. Screening for hepatitis B virus infection in nonpregnant adolescents and adults: US Preventive Services Task Force recommendation statement. Annals of internal medicine. 2014;161(1):58-66.
- Lok AS, McMahon BJ. AASLD practice guideline update. Hepatology. 2009.
- Weinbaum CM1 WI, Mast EE, Wang SA, Finelli L, Wasley A, Neitzel SM, Ward JW. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. Morbidity and Mortality Weekly Report 2008;19(57 (RR-8)):1-20.
- Fattovich G, Bortolotti F, Donato F. Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors. J Hepatol. 2008;48(2):335-52.
- Hoofnagle JH, Di Bisceglie AM. Serologic diagnosis of acute and chronic viral hepatitis. Semin Liver Dis. 1991;11(2):73-83.
- Krugman S, Overby LR, Mushahwar IK, Ling CM, Frosner GG, Deinhardt F. Viral hepatitis, type B. Studies on natural history and prevention re-examined. N Engl J Med. 1979;300(3):101-6.
- Beasley RP. Hepatitis B virus. The major etiology of hepatocellular carcinoma. Cancer. 1988;61(10):1942-56.
- McMahon BJ. The natural history of chronic hepatitis B virus infection. Hepatology. 2009;49(5 Suppl):S45-55.
- Mitchell T, Armstrong, G. L., Hu, D. J., Wasley, A., & Painter, J. A. The Increasing Burden of Imported Chronic Hepatitis B—United States, 1974–2008. PLoS ONE. 2013;8(3):10-1371.
- Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016;63(1):261-83.
- Hsu C, Tsou HH, Lin SJ, Wang MC, Yao M, Hwang WL, et al. Chemotherapy-induced hepatitis B reactivation in lymphoma patients with resolved HBV infection: a prospective study. Hepatology. 2014;59(6):2092-100.
- Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N. Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant. MMWR Morb Mortal Wkly Rep 2018;67:455–458.
- Bruce MG, Bruden D, Hurlburt D, Zanis C, Thompson G, Rea L, et al. Antibody Levels and Protection After Hepatitis B Vaccine: Results of a 30-Year Follow-up Study and Response to a Booster Dose. J Infect Dis. 2016;214(1):16-22.
- Pan CQ, Duan Z, Dai E, Zhang S, Han G, Wang Y, et al. Tenofovir to Prevent Hepatitis B Transmission in Mothers with High Viral Load. N Engl J Med. 2016;374(24):2324-34.
- Schillie S, Murphy TV, Sawyer M, Ly K, Hughes E, Jiles R, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep. 2013;62(RR-10):1-19.
- Service USPH. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep. 2001;50(RR-11):1-52.
- Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. Clin Infect Dis. 2011;53(1):68-75.