Viral Hepatitis

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Hepatitis A

Hepatitis A, caused by infection with the hepatitis A virus (HAV), has an incubation period of approximately 28 days (range: 15–50 days) (819). HAV replicates in the liver and is shed in high concentrations in feces from 2–3 weeks before to 1 week after the onset of clinical illness. HAV infection produces a self-limited disease that does not result in chronic infection or CLD. However, up to 10% of patients experience a relapse of symptoms during the 6 months after acute illness. Acute liver failure from hepatitis A is rare (overall case-fatality rate: 0.5%). The risk for symptomatic infection is directly related to age, with >70% of adults having symptoms compatible with acute viral hepatitis and most children having either asymptomatic or unrecognized infection. Antibody produced in response to HAV infection persists for life and confers protection against reinfection (820).

HAV infection is primarily transmitted by the fecal-oral route, by either person-to-person contact or through consumption of contaminated food or water (821). Transmission of HAV during sexual activity probably results from fecal-oral contact; however, efforts to promote good personal hygiene have not been successful in interrupting outbreaks of hepatitis A. Although viremia occurs early in infection and can persist for several weeks after onset of symptoms, bloodborne transmission of HAV is uncommon (822). Transmission by saliva has not been demonstrated.

In the United States, of the hepatitis A cases accompanied by risk information reported during 2010, a particular risk was identified in only 25% (823). Among adults with identified risk factors, most cases occurred among sexual and household contacts; those with children attending a nursery, daycare, or preschool and persons working in such settings; MSM; IDUs (823); international travelers; and persons exposed to a common-source food or water outbreak.

Diagnostic Considerations

The diagnosis of hepatitis A cannot be made on a clinical basis alone, but rather requires serologic testing. The presence of IgM antibody to HAV is diagnostic of acute HAV infection. A positive test for total anti-HAV indicates immunity to HAV infection but does not differentiate current from previous HAV infection. Although usually not sensitive enough to detect the low level of protective antibody after vaccination, anti-HAV tests also might be positive after hepatitis A vaccination.

Treatment

Patients with acute hepatitis A usually require only supportive care, with no restrictions in diet or activity. Hospitalization might be necessary for patients who become dehydrated because of nausea and vomiting and is critical for patients with signs or symptoms of acute liver failure. Medications that might cause liver damage or are metabolized by the liver should be used with caution among persons with hepatitis A.

Prevention

Vaccination is the most effective means of preventing HAV transmission among persons at risk for infection (e.g., MSM, drug users, and persons with CLD). Hepatitis A vaccines are prepared from formalin-inactivated, cell-culture–derived HAV. Two monovalent vaccines (HAVRIX, GlaxoSmithKline; VAQTA, Merck and Co., Inc.) are cleared by FDA for persons aged ≥12 months (Table 2), and these vaccines are available to eligible children and adolescents aged <19 years through the VFC program (telephone: 800–232–4636).

Administered IM in a 2-dose series at 0 and 6–18 months, hepatitis A vaccines induce protective antibody levels in virtually all adults: by 1 month after the first dose, 94%–100% of adults have protective antibody levels and after a second dose, 100% achieve protective levels (2). Kinetic models of antibody decline indicate that protective levels of antibody persist for at least 20 years. A study in persons who are Alaska Natives demonstrated that seropositivity for hepatitis A persists for at least 10 years after completing 2-dose vaccination at age 12–21 months (824). Sustained protection and the need for booster dosing will continue to be assessed (825,826). A combined hepatitis A and hepatitis B vaccine (Twinrix) has been developed and licensed for use as a 3-dose series in adults aged ≥18 years at risk for hepatitis A and hepatitis B infections (Table 3). When administered IM on a 0-, 1-, and 6-month schedule, the vaccine has equivalent immunogenicity to that of the monovalent vaccines.

Immune globulin (IG) administered IM can provide postexposure prophylaxis against HAV. IG is a sterile solution of concentrated immunoglobulins prepared from pooled human plasma processed by cold ethanol fractionation. In the United States, IG is produced only from plasma that has tested negative for hepatitis B surface antigen, antibodies to HIV and HCV, and HIV and HCV RNA. In addition, the process used to manufacture IG inactivates viruses (e.g., HBV, HCV, and HIV). When administered IM within 2 weeks after exposure to HAV, IG is >85% effective in preventing HAV infections (827).

Pre-exposure Vaccination

The following persons seeking STD services should be offered hepatitis A vaccine: 1) all MSM; 2) drug users (injection and noninjection illicit drugs); and 3) persons with CLD, including persons with chronic HBV and HCV infection who have evidence of CLD. If persons are at risk for both hepatitis A and hepatitis B, the combined vaccine can be considered.

Prevaccination Serologic Testing

Approximately one third of the U.S. population has serologic evidence of previous HAV infection, the prevalence of which increases with age (828). The potential cost-savings of prevaccination testing for susceptibility should be weighed against cost and the likelihood that testing will interfere with initiating vaccination; serologic testing should not be a barrier to vaccination of at-risk populations. In these cases, the first vaccine dose should be administered immediately after collection of the blood sample for serologic testing. Vaccination of a person who is already immune is not harmful. Persons who have a documented history of ≥2-dose hepatitis A vaccination do not need further vaccination or serologic testing.

TABLE 2. Recommended regimens: dose and schedule for hepatitis A vaccines

Vaccine Age (yrs) Dose Volume (mL) Two-dose schedule (months)*
HAVRIX 1–18 720 (EL.U.) 0.5 0 (6–12)
>18 1,440 (EL.U.) 1.0 0 (6–12)
VAQTA§ 1–18 25 (U) 0.5 0 (6–18)
>18 50 (U) 1.0 0 (6–18)

Source: CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(No. RR-7).
Abbreviations: EL.U = Enzyme-linked immunosorbent assay (ELISA) units; U = units.
* 0 months represents timing of the initial dose; subsequent numbers represent months after the initial dose.
Hepatitis A vaccine, inactivated, GlaxoSmithKline Biologicals; this vaccine is also licensed for a 3-dose series in children aged 2–18 years, with 360 EL.U, 0.5 mL doses at 0, 1, and 6–12 months.
§ Hepatitis A vaccine, inactivated, Merck and Co., Inc.

Postvaccination Serologic Testing

Postvaccination serologic testing for immunity is not indicated because most persons respond to the vaccine. In addition, the commercially available serologic test is not sensitive enough to detect the low but protective levels of antibody produced by vaccination.

Postexposure Prophylaxis

Persons who recently have been exposed to HAV and who previously have not received hepatitis A vaccine should be administered a single dose of monovalent hepatitis A vaccine or IG (0.02 mL/kg) as soon as possible, ideally within 2 weeks of exposure because the efficacy of vaccine or IG or vaccine when administered >2 weeks after exposure has not been established (820). Information about the relative efficacy of vaccine compared with IG postexposure is limited, and no data are available for persons aged >40 years or those with underlying medical conditions. Therefore, decisions to use vaccine versus IG should be informed by patient characteristics associated with more severe manifestations of hepatitis A (including older age and CLD) and the magnitude of the risk for HAV transmission resulting from the exposure.

IG should be used for children aged <12 months, immunocompromised persons, persons who have had diagnosed CLD, and persons for whom vaccine is contraindicated. For persons aged >40 years, IG is preferred because of the absence of information regarding vaccine performance and the more severe manifestations of hepatitis A in this age group; vaccine can be used if IG cannot be obtained. For healthy persons aged 12 months to 40 years, monovalent hepatitis A vaccine at the age-appropriate dose is preferred over IG because of the advantages associated with vaccination, including long-term protection and ease of administration.

If IG is administered to persons for whom hepatitis A vaccine also is recommended, a dose of vaccine should be provided simultaneously with IG, and the second vaccine dose should be administered according to the licensed schedule to complete the series. The combined vaccine can be considered in persons for whom both hepatitis A and hepatitis B vaccine is recommended.

Special Considerations

Limited data indicate that hepatitis A vaccination of persons with CLD and of persons with advanced HIV infection results in lower efficacy and antibody concentrations (247). In persons with HIV infection, antibody response can be directly related to CD4+ levels.

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Hepatitis B

Hepatitis B is caused by infection with the hepatitis B virus (HBV). The incubation period from time of exposure to onset of symptoms is 6 weeks to 6 months. The highest concentrations of HBV are found in blood, with lower concentrations found in other body fluids including wound exudates, semen, vaginal secretions, and saliva (829,830). HBV is more infectious and more stable in the environment than other bloodborne pathogens (e.g., HCV and HIV).

HBV infection can be self-limited or chronic. In adults, approximately half of newly acquired HBV infections are symptomatic, and approximately 1% of reported cases result in acute liver failure and death (831). Risk for chronic infection is inversely related to age at acquisition; approximately 90% of infected infants and 30% of infected children aged <5 years become chronically infected compared with 2%–6% of persons who become infected as adults (832). Among persons with chronic HBV infection, the risk for premature death from cirrhosis or hepatocellular carcinoma (HCC) is 15%–25% (833).

HBV is efficiently transmitted by percutaneous or mucous membrane exposure to HBV-infected blood or body fluids that contain HBV. The primary risk factors associated with infection among adolescents and adults are unprotected sex with an infected partner, multiple partners, MSM, history of other STDs, and injection-drug use. In addition, several studies have demonstrated other modes of HBV transmission, including premastication and lapses in health-care infection-control procedures, as less common sources of transmission (244,834-836).

TABLE 3. Interpretation of serologic test results* for HBV infection

Serologic marker

Interpretation

HBsAg

Total anti-HBc

IgM anti-HBc

Anti-HBs

Never infected

+

Early acute infection; transient (up to 18 days) after vaccination

+

+

+

Acute infection

+

+

Acute resolving infection

+

+

Recovered from past infection and immune

+

+

Chronic infection

+

False positive (i.e., susceptible); past infection; “low-level” chronic infection§; passive transfer to infant born to HBsAg-positive mother

+

Immune if concentration is >10 mIU/mL, passive transfer after HBIG administration

 

Abbreviations: anti-HBc = antibody to hepatitis B core antigen; anti-HBs = antibody to hepatitis B surface antigen; HBsAg = hepatitis B surface antigen; IgM = immunoglobulin M; mIU/mL = Milli-international units per milliliter.

* Symbol for negative test result, “–“; symbol for positive test result, “+.”
To ensure that an HBsAg-positive test result is not false-positive, samples with repeatedly reactive HBsAg results should be tested with an FDA-cleared neutralizing confirmatory test.
§ Persons positive for only anti-HBc are unlikely to be infectious except under unusual circumstances involving direct percutaneous exposure to large quantities of blood (e.g., blood transfusion and organ transplantation).

CDC’s national strategy to eliminate transmission of HBV infection includes 1) prevention of perinatal infection through routine screening of all pregnant women for HBsAg and immunoprophylaxis of infants born to mothers with HBsAg or mothers whose HBsAg status is unknown, 2) routine infant vaccination, 3) vaccination of previously unvaccinated children and adolescents through age 18 years, and 4) vaccination of previously unvaccinated adults at increased risk for infection (3,4). High vaccination coverage rates with subsequent declines in acute hepatitis B incidence have been achieved among infants and adolescents (4,823,837). The aging of persons vaccinated as children and adolescents likely has led to improved vaccination coverage in adults aged <30 years (838) and corresponding lower rates of acute HBV infection in this group. In contrast, vaccination coverage among most high-risk adult populations aged >30 years (e.g., persons with multiple sex partners, MSM, and IDUs) has remained low; these groups account for the highest rates of preventable acute infections (3,169,838-840). STD clinics and other settings providing STD services to high-risk adults should administer hepatitis B vaccine to those who are unvaccinated, as adults seeking STD services are at risk for this infection.

Diagnosis

Diagnosis of acute or chronic HBV infection requires serologic testing (Table 3). Because HBsAg is present in both acute and chronic infection, the presence of IgM antibody to hepatitis B core antigen (IgM anti-HBc) is diagnostic of acute or recently acquired HBV infection. Antibody to HBsAg (anti-HBs) is produced after a resolved infection and is the only HBV antibody marker present after vaccination. The presence of HBsAg and total anti-HBc, with a negative test for IgM anti-HBc, indicates chronic HBV infection. The presence of anti-HBc alone might indicate acute, resolved, or chronic infection or a false-positive result.

Treatment

No specific therapy is available for persons with acute hepatitis B; treatment is supportive. Persons with chronic HBV infection should be referred for evaluation to a provider experienced in the management of chronic HBV infection. Therapeutic agents cleared by FDA for treatment of chronic hepatitis B can achieve sustained suppression of HBV replication and remission of liver disease (841).

Prevention

Two products have been approved for hepatitis B prevention: hepatitis B immune globulin (HBIG) for postexposure prophylaxis and hepatitis B vaccine (3,4). HBIG provides temporary (i.e., 3–6 months) protection from HBV infection and is typically used as PEP as an adjunct to hepatitis B vaccination (in previously unvaccinated persons) or in persons who have not responded to vaccination. HBIG is prepared from plasma known to contain high concentrations of anti-HBs. The recommended dose of HBIG is 0.06 mL/kg.

Hepatitis B vaccine contains HBsAg produced in yeast by recombinant DNA technology and provides protection from HBV infection when used for both pre-exposure vaccination and PEP. The two available monovalent hepatitis B vaccines for use in the United States are Recombivax HB (Merck and Co., Inc., Whitehouse Station, New Jersey) and Engerix-B (GlaxoSmithKline Biologicals, Pittsburgh, Pennsylvania). A combination hepatitis A and hepatitis B vaccine for use in persons >18 years, Twinrix (GlaxoSmithKline Biologicals, Pittsburgh, Pennsylvania), also is available.

TABLE 4. Recommended doses of currently licensed formulations of adolescent and adult hepatitis B vaccines

Group

Single-antigen vaccine

Combination vaccine

Recombivax HB

Engerix-B

Twinrix*

Dose (µg)

Volume (mL)

Dose (µg)

Volume (mL)

Dose (µg)

Volume (mL)

Adolescents aged 11–19 years§

5

0.5

10

0.5

NA

NA

Adolescents aged 11–15 years

10

1.0

NA

NA

NA

NA

Adults (aged ≥20 years)

10

1.0

20

1.0

20

1.0

Hemodialysis and other immunocompromised persons aged <20 years §

5

0.5

10

0.5

NA

NA

Hemodialysis and other immunocompromised persons aged ≥20 years

   40**

1.0

40††

2.0

NA

NA

Sources: CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: immunization of infants, children, and adolescents. MMWR Recomm Rep 2005;54(No. RR-16). CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006;55(No. RR-16).
* Combined hepatitis A and hepatitis B vaccine. This vaccine is recommended for persons aged ≥18 years at increased risk for both hepatitis B and hepatitis A virus infections.
Recombinant hepatitis B surface antigen protein dose, in micrograms.
§ Pediatric formulation administered on a 3-dose schedule; higher doses might be more immunogenic, but no specific recommendations have been made.
Adult formulation administered on a 2-dose schedule.
** Dialysis formulation administered on a 3-dose schedule at 0, 1, and 6 months.
†† Two 1.0-mL doses of the adult formulation administered at one site on a 4-dose schedule at 0, 1, 2, and 6 months.

When selecting a hepatitis B vaccination schedule, health-care providers should consider the need to achieve completion of the vaccine series. The recommended HBV dose and schedule varies by product and age of recipient (Table 4). Three different 3-dose schedules for adolescents and adults have been approved for both monovalent hepatitis B vaccines (i.e., Engerix-B and Recombivax HB); these vaccines can be administered at 0, 1, and 6 months; 0, 1, and 4 months; and 0, 2, and 4 months. A 4-dose schedule of Engerix-B at 0, 1, 2, and 12 months is licensed for all age groups. A 2-dose schedule of Recombivax HB adult formulation (10 µg) is licensed for adolescents aged 11–15 years, with a 4 month minimal interval between doses. When scheduled to receive the second dose, adolescents aged 16–19 years should be switched to a 3-dose series, with doses two and three consisting of the pediatric formulation (5 µg) administered on an appropriate schedule. Twinrix is a 3-dose schedule administered at 0, 1, and 6 months to persons aged ≥18 years at risk for both HAV and HBV infections.

Hepatitis B vaccine should be administered IM in the deltoid muscle and can be administered simultaneously with other vaccines. If the vaccine series is interrupted after the first or second dose of vaccine, the missed dose should be administered as soon as possible. The series does not need to be restarted after a missed dose. HBV vaccination is available for eligible children and adolescents aged <19 years through the VFC program (telephone: 800–232–4636).

In adolescents and healthy adults aged <40 years, approximately 30%–55% achieve a protective antibody response (i.e., anti-HBs ≥10 mIU/mL) after the first vaccine dose, 75% after the second, and >90% after the third. Vaccine-induced immune memory has been demonstrated to persist for at least 20 years (837,842,843). Periodic testing to determine antibody levels after routine vaccination in immunocompetent persons is not necessary, and booster doses of vaccine are not currently recommended.

Hepatitis B vaccination is generally well tolerated by most recipients. Pain at the injection site and low-grade fever are reported by a minority of recipients. For children and adolescents, a causal association exists between receipt of hepatitis B vaccination and anaphylaxis: for each 1.1 million doses of vaccine administered, approximately one vaccinee will experience this type of reaction. No deaths have been reported in these patients (3,4,839). Vaccine is contraindicated in persons with a history of anaphylaxis after a previous dose of hepatitis B vaccine and in persons with a known anaphylactic reaction to any vaccine component. No other adverse events after administration of hepatitis B vaccine have been demonstrated.

Pre-exposure Vaccination

Hepatitis B vaccination is recommended for all unvaccinated children and adolescents, all unvaccinated adults at risk for HBV infection (especially IDU, MSM, and adults with multiple sex partners), and all adults seeking protection from HBV infection (3). For adults, acknowledgment of a specific risk factor is not a requirement for vaccination.

Hepatitis B vaccine should be routinely offered to all unvaccinated persons attending STD clinics and to all unvaccinated persons seeking evaluation or treatment for STDs in other settings, especially correctional facilities, facilities providing drug-abuse treatment and prevention services, federally qualified health centers, and settings serving MSM (e.g., HIV care and prevention settings). If hepatitis B vaccine is unavailable at a particular facility, persons should be linked to a setting where they can receive vaccine. Persons with a reliable vaccination history (i.e., a written, dated record of each dose of a complete series) or reliable history of hepatitis B infection (i.e., a written record of infection and serologic results showing evidence of past infection) do not require vaccination. In all settings, vaccination should be initiated at the initial visit, even if concerns about completion of the vaccine series exist.

Prevaccination Serologic Testing

Conducting prevaccination serologic testing for susceptibility just before the initial vaccine dose is administered might be considered to reduce the cost of completing the vaccination series in adult populations that have an expected high prevalence (20%–30%) of HBV infection (e.g., IDUs and MSM, especially those in older age groups). In addition, prevaccination testing for susceptibility is recommended for unvaccinated household, sexual, and needle-sharing contacts of HBsAg-positive persons (169). Serologic testing should not be a barrier to vaccination. 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.

Anti-HBc is the test of choice for prevaccination testing. Persons who are anti-HBc–positive should be tested for HBsAg. If persons are determined to be HBsAg negative, no further action is required. Persons with 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).

Postvaccination Serologic Testing for Response

Postvaccination serologic testing for immunity is not necessary after routine vaccination of adolescents or adults. However, such testing is recommended for persons whose subsequent clinical management depends on knowledge of their immune status (e.g., health-care workers or public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids). In addition, postvaccination testing is recommended for 1) persons with HIV infection and other immunocompromised persons to determine the need for revaccination and 2) sex and needle-sharing partners of HBsAg-positive persons to determine the need for revaccination and other methods to protect themselves from HBV infection.

If indicated, anti-HBs testing should be performed 1–2 months after administration of the last dose of the vaccine series. Persons determined to have anti-HBs levels of <10 mIU/mL after the primary vaccine series should be revaccinated with a 3-dose series and tested again for anti-HBs 1–2 months after the third dose. Persons who do not respond to revaccination should be tested for HBsAg. If HBsAg positive, the person should receive appropriate management (see Management of HBsAg-Positive Persons); if HBsAg negative, the person should be considered susceptible to HBV infection and counseled concerning precautions to prevent HBV infection and the need for HBIG PEP for any known exposure (see Postexposure Prophylaxis).

Postexposure Prophylaxis

Both passive-active PEP (the simultaneous administration of HBIG [i.e., 0.06 mL/kg] and hepatitis B vaccine at separate sites) and active PEP (the administration of hepatitis B vaccination alone) have been demonstrated to be highly effective in preventing transmission after exposure to HBV (4). HBIG alone also has been demonstrated to be effective in preventing HBV transmission, but with the availability of hepatitis B vaccine, HBIG typically is used as an adjunct to vaccination.

Exposure to an HBsAg-Positive Source

Unvaccinated persons or persons known not to have responded to a complete hepatitis B vaccine series should receive both HBIG and hepatitis vaccine as soon as possible (preferably ≤24 hours) after a discrete, identifiable exposure to blood or body fluids that contain blood from a person with HBsAg (Table 5). Hepatitis B vaccine should be administered simultaneously with HBIG at a separate injection site, and the vaccine series should be completed by using the age-appropriate vaccine dose and schedule (Table 4). Exposed persons who are in the process of being vaccinated but who have not completed the vaccine series should receive HBIG (i.e., 0.06 mL/kg) and complete the vaccine series. Exposed persons who are known to have responded to vaccination are considered protected; therefore, they need no additional doses of vaccine or HBIG. Persons who have written documentation of a complete hepatitis B vaccine series who did not receive postvaccination testing should receive a single vaccine booster dose. These persons should be managed according to guidelines for management of persons with occupational exposure to blood or body fluids that contain HBV (844).

Exposure to a Source with Unknown HBsAg Status

Unvaccinated persons and persons with previous nonresponse to hepatitis B vaccination who have a discrete, identifiable exposure to blood or body fluids containing blood from a person with unknown HBsAg status should receive the hepatitis B vaccine series, with the first dose initiated as soon as possible after exposure (preferably <24 hours) and the series completed using the age-appropriate dose and schedule. Exposed persons who are not fully vaccinated should complete the vaccine series. Generally, exposed persons with written documentation of a complete hepatitis B vaccine series who did not receive postvaccination testing require no further treatment.

TABLE 5. Guidelines for postexposure prophylaxis* of persons with nonoccupational exposure to blood or body fluids that contain blood, by exposure type and vaccination status

Source of exposure

Treatment

Unvaccinated person§

Previously vaccinated person

HBsAg-positive source    
Percutaneous (e.g., bite or needlestick) or mucosal exposure to HBsAg-positive blood or body fluids Administer hepatitis B vaccine series and HBIG Administer hepatitis B vaccine booster dose
Sex or needle-sharing contact of an HBsAg-positive person Administer hepatitis B vaccine series and HBIG Administer hepatitis B vaccine booster dose
Victim of sexual assault/abuse by a perpetrator who is HBsAg positive Administer hepatitis B vaccine series and HBIG Administer hepatitis B vaccine booster dose
Source with unknown HBsAg status    
Victim of sexual assault/abuse by a perpetrator with unknown HBsAg status Administer hepatitis B vaccine series No treatment
Percutaneous (e.g., bite or needlestick) or mucosal exposure to potentially infectious blood or body fluids from a source with unknown HBsAg status Administer hepatitis B vaccine series No treatment
Sex or needle-sharing contact of person with unknown HBsAg status Administer hepatitis B vaccine series No treatment

Source: CDC. Postexposure prophylaxis to prevent hepatitis B virus infection. MMWR Recomm Rep 2006;55(No. RR-16).

Abbreviations: HBIG = hepatitis B immune globulin. HBsAg = hepatitis B surface antigen.

* When indicated, immunoprophylaxis should be initiated as soon as possible, preferably within 24 hours. Studies are limited on the maximum interval after exposure during which postexposure prophylaxis is effective, but the interval is unlikely to exceed 7 days for percutaneous exposures or 14 days for sexual exposures. The hepatitis B vaccine series should be completed.

These guidelines apply to nonoccupational exposures. Guidelines for management of occupational exposures have been published separately and also can be used for management of nonoccupational exposures, if feasible. 

Source: CDC. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013;62(No. RR-10.

§ A person who is in the process of being vaccinated but who has not completed the vaccine series should complete the series and receive treatment as indicated.

A person who has written documentation of a complete hepatitis B vaccine series and who did not receive postvaccination testing.

Special Considerations

Pregnancy

Regardless of whether they have been previously tested or vaccinated, all pregnant women should be tested for HBsAg at the first prenatal visit and at delivery if at high risk for HBV infection (see Special Populations Pregnant Women). Pregnant women at risk for HBV infection should receive hepatitis B vaccination. All pregnant women with HBsAg should be reported to state and local perinatal hepatitis B prevention programs and referred to a specialist. Information on the management of pregnant women with HBsAg and their infants is available at https://www.cdc.gov/mmwr/PDF/rr/rr5416.pdfCdc-pdf.

HIV Infection

HIV infection can impair the response to hepatitis B vaccination. Persons with HIV infection should be tested for anti-HBs 1–2 months after the third vaccine dose (see Postvaccination Serologic Testing). Modified dosing regimens, including a doubling of the standard antigen dose and administration of additional doses, might increase the response rate (247). Additional recommendations for management of persons with HBsAg and HIV infection are available (247).

Management of HBsAg-Positive Persons

Recommendations for management of all persons with HBsAg-include the following:

  • All persons with HBsAg documented on laboratory results should be reported to the state or local health department.
  • To verify the presence of chronic HBV infection, persons with HBsAg should be retested. The absence of IgM anti-HBc or the persistence of HBsAg for 6 months indicates chronic HBV infection.
  • Persons with chronic HBV infection should be referred for evaluation to a specialist experienced in the management of chronic hepatitis B infection.
  • Household, sexual, and needle-sharing contacts of chronically infected persons should be evaluated. Unvaccinated sex partners and household and needle-sharing contacts should be tested for susceptibility to HBV infection (see Prevaccination Serologic Testing) and 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 by using an age-appropriate vaccine dose and schedule.
  • Sex partners of persons with HBsAg should be counseled to use latex condoms (32) to protect themselves from sexual exposure to infectious body fluids (e.g., semen and vaginal secretions), unless they have been demonstrated to be immune after vaccination (anti-HBs ≥10 mIU/mL) or previously infected (anti-HBc positive).
  • To prevent or reduce the risk for transmission to others in addition to vaccination, persons with HBsAg also should be advised to:
    • use methods (e.g., condoms) to protect nonimmune sex partners from acquiring HBV infection from sexual activity until the partner can be vaccinated and immunity documented;
    • cover cuts and skin lesions to prevent spread by infectious secretions or blood;
    • refrain from donating blood, plasma, body organs, other tissue, or semen; and
    • refrain from sharing household articles (e.g., toothbrushes, razors, or personal injection equipment) that could become contaminated with blood and 
    • refrain from premastication of food.
  • To protect the liver from further harm, persons with HBsAg should be advised to:
    • avoid or limit alcohol consumption because of the effects of alcohol on the liver;
    • refrain from starting any new medicines, including OTC and herbal medicines, without checking with their health-care provider; and
    • obtain vaccination against hepatitis A.

When seeking medical or dental care, HBsAg-positive persons should be advised to inform their health-care providers of their HBsAg status so that they can be appropriately evaluated and managed. The following are key counseling messages for persons with HBsAg:

  • HBV is not usually spread by hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact.
  • Persons should not be excluded from work, school, play, child care, or other settings because they are infected with HBV.
  • Involvement with a support group might help patients cope with chronic HBV infection.

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