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Hepatitis B FAQs for Health Professionals

Index of Questions

Show± Overview and Statistics

Show± Transmission, Symptoms, and Treatment

Show± Hepatitis B Serology

Show± Hepatitis B Vaccination

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:

Additional guidance on viral hepatitis surveillance and case management is available at https://www.cdc.gov/hepatitis/SurveillanceGuidelines.htm.

How many new HBV infections occur annually in the United States?

In 2016, a total of 3,218 cases of acute hepatitis B were reported to CDC from 48 states. The overall incidence rate for 2016 was 1.0 cases per 100,000 population. After adjusting for under-ascertainment and under-reporting, an estimated 20,900 acute hepatitis B cases occurred in 2016 (1 ).

Has the rate of new HBV infections in the United States declined?

The rate of new HBV infections has declined from 1990–2014. The decline has been greatest among children born since 1991, when routine vaccination of children was first recommended. Since 2000, the number of reported cases of HBV infections have continued to drop from 8,036 to 3,218 in 2016 (1). Since 2014, there has been an increase in the rate of new HBV infections, which is likely due to increasing injection drug use (2).

Figure. Incidence of acute hepatitis B, by year United States, 2006–2016

Incidence of Acute Hepatitis B, by year United States

How common is chronic HBV infection in the United States?

During 2011-2012, there were almost 847,000 noninstitutionalized persons in the United States with chronic hepatitis B virus infection(3). A 2009 estimate, using other adjustment methods, reported chronic hepatitis B virus infections to be as high as 2.2 million (4)

Where can I find more information about viral hepatitis incidence and prevalence in the United States?

Viral hepatitis surveillance reports and guidelines are available at https://www.cdc.gov/hepatitis/statistics.htm.

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, 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 or open sores of an infected person
  • Needle sticks or sharp instrument exposures
  • Sharing items such as razors or 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 cleaned using 1:10 dilution of one part household bleach to 10 parts of water for disinfecting the area. Gloves should be worn when cleaning up any blood spills.

Who is at risk for HBV infection?

The following populations are at increased risk of 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 to 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).

Persons who should be screened for HBV (79):

  • Persons born in countries with 2% or higher HBV prevalence
  • Men who have sex with men
  • Persons who inject drugs
  • HIV-positive persons
  • Household and sexual contacts of HBV-infected persons
  • Persons requiring immunosuppressive therapy
  • Persons with end-stage renal disease (including hemodialysis patients)
  • Blood and tissue donors
  • Persons infected with hepatitis C
  • Persons with elevated alanine aminotransferase levels (>19 IU/L for women and >30 IU/L for men)
  • Incarcerated persons
  • 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 persons 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 persons aged ≥5 years have signs and symptoms (10). When present, signs and symptoms of acute HBV infections can include

  • Fever
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting
  • Abdominal pain
  • Dark urine
  • Clay-colored bowel movements
  • Joint pain
  • Jaundice

Some acute HBV infections will resolve on their own, but some will develop into chronic infection. Most persons with chronic HBV infection are asymptomatic and have no evidence of liver disease. However, some persons 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?

If symptoms occur, they begin an average of 90 days (range: 60–150 days) after exposure to HBV (11, 12).

When symptoms of acute hepatitis B occur, how long do they usually last?

Symptoms typically last for several weeks but can persist for up to 6 months (11, 12).

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. The fatality rate among the 3,370 acute cases reported to CDC in 2015 was 0.9% (1).

How serious is chronic HBV infection?

Approximately 25% of those 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). There were 1,715 deaths related to HBV reported to the CDC in 2015, but this is an underestimate, and the estimated annual deaths due to HBV are 14,000 (15). https://www.cdc.gov/hepatitis/statistics/2015surveillance/index.htm

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.

There are several antiviral medications for persons with chronic infection (16). Persons with chronic HBV infection require linkage to care with regular monitoring to prevent liver damage and/or hepatocellular carcinoma.  American Association for the Study of Liver Diseases (AASLD) Practice guidelines are available for the treatment of Chronic Hepatitis B and can be found on this site: http://www.aasld.org/publications/practice-guidelines-0.

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 in the following categories are at highest risk for HBV reactivation:

  • Patients undergoing cancer chemotherapy
  • Patients taking immunosuppressive therapy
    • 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.

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. Persons 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 these sites: http://hcvguidelines.org/ and https://www.aasld.org/publications/practice-guidelines-0.

Hepatitis B Serology

Where can I learn in detail about HBV serology?

CDC offers an online training that covers hepatitis B serology and other types of viral hepatitis: http://www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm.

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 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. There are several commercial assays that 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.

Table. Antibody and Antigen Biomarkers for Hepatitis B Infection (6)

Table. Antibody and Antigen Biomarkers for Hepatitis B Infection 
Clinical state HBsAg Total Anti-HBs Total anti-HBc Action
Chronic infection Positive Negative Positive Link to hepatitis B-directed care
Acute Positive Negative Positive
(IgM anti-HBc)
Link to hepatitis B-directed care
Resolved infection Negative Positive Positive Counseling, reassurance
Immune (immunization) Negative Positive Negative Reassurance
Susceptible
(never infected and no evidence of immunization)
Negative Negative Negative Vaccinate
*Isolated core antibody Negative Negative Positive Depends on situation

*can be a result of:

1 False positive: Repeat testing required
2 Past infection: No action needed
3 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.
4 Passive transfer to infant born to HBsAg-positive mother No specific action needed.

Hepatitis B surface antigen (HBsAg): A protein on the surface of HBV; it can be detected in high levels in serum during acute or chronic HBV infection. The presence of HBsAg indicates that the person is infectious. 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.

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).

Where can I learn more about HBV serology?

CDC offers an online training that covers the serology of hepatitis B and other types of viral hepatitis, available at https://www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm.

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 persons
    • Sexually active people who are not in a long-term, mutually monogamous relationship (e.g., persons 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; persons 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, persons 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 infection
  • 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. The Advisory Committee on Immunization Practices 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
  • Institutions and nonresidential day care facilities for developmentally disabled persons

What are the hepatitis B vaccines licensed for use in the United States?

Three single-antigen vaccines and three combination vaccines are currently licensed in the United States.

Single-antigen hepatitis B vaccines

  1. ENGERIX-B®
  2. RECOMBIVAX HB®
  3. HEPLISAV-B™

Combination vaccines

  • 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 persons aged ≥18 years who are at increased risk for both Hepatitis A virus and HBV infections.

What are the recommended schedules for hepatitis B vaccination?

The vaccination schedule most often used for children and adults is 3 intramuscular injections, the second and third doses administered 1 and 6 months, respectively, after the first dose. Alternate schedules have been approved for certain vaccines and/or populations.

What are the recommended doses of hepatitis B vaccines?

Recommended doses of currently licensed formulations of hepatitis B vaccine,
by age group and vaccine type
Age Group Single-antigen vaccine Combination vaccine
Recombivax HB Engerix-B Pediarix Twinrix§
Dose
(μg)
Vol(mL) Dose
(μg)
Vol(mL) Dose
(μg)
Vol (mL) Dose
(μg)
Vol (mL)
Infants (<1 yr)
5 0.5 10 0.5 10 0.5 NA** NA
Children (1–10 yrs)
5 0.5 10 0.5 10 0.5 NA NA
Adolescents
11–15 yrs 10†† 1.0 NA NA NA NA NA NA
11–19 yrs 5 0.5 10 0.5 NA NA NA NA
Adults (20 yrs)
10 1.0 20 1.0 NA NA 20§ 1.0
Hemodialysis patients
and other immuno-
compromised persons
<20 yrs§§ 5 0.5 10 0.5 NA NA NA NA
20 yrs 40¶¶ 1.0 40*** 2.0 NA NA NA NA

Combined hepatitis B, diphtheria, tetanus, acellular pertussis adsorbed, inactivated poliovirus vaccine. This vaccine cannot be administered at birth, before age 6 weeks, or at age >7 years.
§ Combined Hepatitis A and hepatitis B vaccine. This vaccine is recommended for persons 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. No differences in immune response are observed when vaccines from different manufacturers are used to complete the vaccine series (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.

  • 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 vaccinated individuals who initiated hepatitis B vaccination >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-0) 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. 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 (https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html). Pregnant women may be at high risk if they:

  • Have had more than one sex partner during the previous six months
  • Are being evaluated or treated for a sexually transmitted infection
  • Have had recent or current injection-drug use
  • Have had a HBsAg-positive sex partner

Can hepatitis B vaccine be given to immunocompromised persons, such as persons on hemodialysis or persons with HIV infection?

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 persons. Serologic testing of hemodialysis patients and other immunocompromised persons 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 persons is available from the Advisory Committee on Immunization Practices recommendations on adult hepatitis B vaccination (available at https://www.cdc.gov/mmwr/PDF/rr/rr5516.pdf [PDF – 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 persons be tested for immunity to hepatitis B before being vaccinated?

Adult populations that have risk factors for HBV transmission or at risk of HBV reactivation should receive complete serologic testing (HBsAg, anti-HBs, and anti-HBc) so that 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. Vaccination of persons 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.

If persons are determined to be HBsAg negative, no further action is required. Persons 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). Persons 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?

Persons 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 persons whose subsequent clinical management depends on knowledge of their immune status, including

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, anti-HBs levels following vaccination decline over time. Anti-HBs ≥10 mIU/mL is considered a correlate of vaccine-induced protection for persons who have completed an approved vaccination series. Immunocompetent persons who achieve an anti-HBs level ≥10 mIU/mL 1–2 months after a complete 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; 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 persons (e.g., HIV-infected persons, hematopoietic stem-cell transplant recipients, and persons 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. Persons with normal immune status who have been vaccinated, booster doses are not recommended (19, 23).

References

    1. CDC. Viral Hepatitis Surveillance–United States, 2016. 2018.
    2. Harris AM, Iqbal K, Schillie S, Britton J, Kainer MA, Tressler S, et al. Increases in Acute Hepatitis B Virus Infections – Kentucky, Tennessee, and West Virginia, 2006-2013. MMWR Morb Mortal Wkly Rep. 2016;65(3):47-50.
    3. Roberts H, Kruszon‐Moran D, Ly KN, Hughes E, Iqbal K, Jiles RB, et al. Prevalence of chronic hepatitis B virus (HBV) infection in US households: National Health and Nutrition Examination Survey (NHANES), 1988‐2012. Hepatology. 2015.
    4. 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.
    5. 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.
    6. 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.
    7. 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.
    8. Lok AS, McMahon BJ. AASLD practice guideline update. Hepatology. 2009.
    9. 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.
    10. 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.
    11. Hoofnagle JH, Di Bisceglie AM. Serologic diagnosis of acute and chronic viral hepatitis. Semin Liver Dis. 1991;11(2):73-83.
    12. 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.
    13. Beasley RP. Hepatitis B virus. The major etiology of hepatocellular carcinoma. Cancer. 1988;61(10):1942-56.
    14. McMahon BJ. The natural history of chronic hepatitis B virus infection. Hepatology. 2009;49(5 Suppl):S45-55.
    15. 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.
    16. 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.
    17. 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.
    18. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep. 2001;50(RR-5):1-43.
    19. 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.
    20. 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.
    21. 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.
    22. 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.
    23. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. Clin Infect Dis. 2011;53(1):68-75.
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