Vaccine Preventable Diseases

Hepatitis B

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Advisory Committee on Immunization Practices (ACIP) Recommendations

Infants
• All medically stable infants weighing ≥2,000 grams without contraindications should receive the first dose of hepatitis B vaccine (trade names: Engerix-B®, Recombivax HB®) within 24 hours of birth.
• Certain infants at increased risk of acquisition of hepatitis B, such as infants born to hepatitis B-infected mothers or mothers with unknown status, should receive hepatitis B vaccine as soon as possible after birth along with a dose of hepatitis B immune globulin.
• The second dose should be administered a minimum of 4 weeks after the first dose and between 1-2 months of age. The third dose should be administered a minimum of 8 weeks after the second and 16 weeks after the first, between 6-18 months of age.

Children, Adolescents and Adults
• All children not previously vaccinated should receive the age-appropriate dose of hepatitis b vaccine, preferably at 11 or 12 years but up to 18 years of age.
• The usual schedule for adolescents is two doses separated by no less than 4 weeks, and a third dose at least 8 weeks from the second dose and 16 weeks from the first dose, and preferably 4 to 6 months after the second dose. An approved alternative schedule for adolescents 11 to 15 years of age is two 1.0-mL doses of the Recombivax HB® vaccine separated by 4 to 6 months.
• Adults at increased risk of hepatitis B infection (including sex partners or household contacts of hepatitis B infected persons; sexually active persons not in a long-term mutually monogamous relationship; persons seeking evaluation or treatment for a sexually transmitted disease; men who have sex with men; current or recent injection drug users; residents and staff of facilities for developmentally disabled persons; health care and public safety workers at risk of exposure to blood or body fluids; persons with end-stage renal disease or diabetes mellitus; HIV-infected individuals; and international travelers to countries with high or intermediate endemnicity) should be vaccinated. If using Recombivax HB® or Engerix-B®, the first two doses should be separated by at least 4 weeks and a third dose administered 4-6 months after the second dose. If using HEPLISAV-B™ vaccine, only two doses (0.5 mL each) are given one month apart, but both doses must be HEPLISAV-B™.
• Persons with chronic liver disease (including, but not limited to, those with hepatitis C virus [HCV] infection, 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) should also be vaccinated [1, 4-7].

For More Information
ACIP recommendations: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html
Immunization schedules: http://www.cdc.gov/vaccines/schedules/index.html
 

Disease 

Hepatitis B Virus (HBV) is a small, double-shelled DNA virus in the Hepadnaviridae family. HBV is transmitted via mucosal exposure to infected body fluids, often during birth, sexual contact, via blood or blood exposure, needlesticks, or injection drug use [1]. The incubation period averages 120 days. Approximately 90% of infants and 50% of adult infections are asymptomatic, and when there are symptoms, they are indistinguishable from those of other types of acute viral hepatitis. Initial symptoms include malaise, anorexia, nausea, vomiting, fever, headache, myalgia, arthralgia, arthritis and dark urine. Further symptoms such as jaundice, light or gray stools, hepatic tenderness and hepatomegaly typically last 1-3 weeks, and begin 3-10 days after the onset of most initial symptoms (1-2 days following the onset of dark urine). Most acute HBV infections result in complete recovery; however, 1-2% of cases result in fulminant hepatitis, which has a case-fatality rate of 63-93% and causes roughly 200-300 deaths in the United States annually. Up to 90% of infants infected at birth by their mothers become chronically infected, and about 25% of those chronically infected will die from cirrhosis or liver cancer. This risk of chronic infection decreases with age, to about 5% of acute infections in adults become chronic. Chronic infection is often asymptomatic until complications develop [1].

Vaccine

Hepatitis B vaccines is a yeast-derived recombinant vaccine containing HBsAg protein. There are two hepatitis B vaccines used in the United States: Recombivax HB®, which is adjuvanted with aluminum hydroxyphosphate sulfate and Engerix-B®, which is adjuvanted with aluminum hydroxide.

There are also several combination vaccines that include hepatitis B vaccine. Hep A-Hep B (Twinrix®) is approved for use in persons over 18 years of age, administered in a three-dose series at 0, 1 and 6 months. Hib-Hep B (Comvax®) is approved for use at 2, 4 and 12-15 months of age. DTaP-Hep B-IPV (Pediarix®) is approved for use at 2, 4 and 6 months of age. Neither Comvax® nor Pediarix® can be used before 6 weeks of age, but eithercan be substituted for doses 2 or 3 of hepatitis B vaccine. Infants may also receive a fourth dose of hepatitis B vaccine as part of a combination vaccine schedule [1].

Vaccine Effectiveness: Over 90% of adults and 95% of children develop protective antibody responses after three doses of vaccine. These vaccines are >95% effective at preventing clinical disease and the chronic carrier state after infection, and estimated to be 80-100% effective in preventing hepatitis B infections after completion of the series. Although antibody levels decline, immunologic memory induced from vaccination persists and serologic responders have been shown to be protective for at least 20 years. Follow-up studies of infants vaccinated at birth have revealed that many adolescents do not develop an anamnestic response (i.e. renewed rapid antibody production on a subsequent encounter with the same antigen) to a booster dose of vaccine, but there is no evidence of an increased rate of breakthrough disease and no routine booster dose has been recommended [1].

Vaccine Safety: Anaphylaxis occurs approximately once per every 1.1 million doses of hepatitis B vaccine administered. Alopecia has been suggested to be rarely associated with hepatitis B vaccination. No causal association between any chronic illnesses and hepatitis B vaccine have been shown [1].

Contraindications and Precautions: Severe allergic reaction (e.g. anaphylaxis) to a previous dose or vaccine component is a contraindication to further vaccination with hepatitis B vaccine. Current moderate to severe acute illness is a precaution to any vaccination [1].

Considerations in Pregnancy: Hepatitis B vaccine is not routinely recommended in pregnancy. However, pregnancy is not a contraindication to hepatitis B vaccination.

Perinatal transmission from mother to infant at birth is very efficient. If a mother is positive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) and postexposure prophylaxis is not administered, 70%–90% of infants will become infected. If the mother is positive only for HBsAg, the risk of perinatal transmission is about 10%. Up to 90% of infant HBV infections will become chronic.

Therefore, prevention of perinatal HBV infection is of the utmost importance. This can be accomplished through routine screening of all pregnant women for hepatitis B surface antigen (HBsAg) and subsequent postexposure immunoprophylaxis of infants born to women who are HBsAg-positiveor of unknown HBsAg status.

Pregnancy is not a contraindication to hepatitis B vaccination. This is because the vaccine contains HBsAg, which is not infectious, and because limited data suggest that developing fetuses are not at risk for adverse events when the vaccine is administered during pregnancy [1, 7, 8].

References

1. Epidemiology and Prevention of Vaccine-Preventable Diseases. Washington D.C.: Centers for Disease Control and Prevention; 2015.
2. Zuckerman JN. Protective efficacy, immunotherapeutic potential, and safety of hepatitis B vaccines. J Med Virol 2006;78(2):169-77.
3. Ocama P, Opio CK, Lee WM. Hepatitis B virus infection: current status. Am J Med 2005;118(12): 1413.
4. Schillie S, Vellozzi C, Reingold A. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2018;67(1):1–31.
5. Schillie S, et al. 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(15): 455-8.
6. Immunization Action Coalition. Merck discontinues production of Comvax vaccine (Hib-HepB). IAC Express 2014; Issue 1136. (last accessed May 2018).
7. Mast EE, Margolis HS, Fiore AE, et al. 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 Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports 2005;54:1-31.
8. Leads from the MMWR. Prevention of perinatal transmission of hepatitis B virus: prenatal screening of all pregnant women for hepatitis B surface antigen. JAMA 1988;260:165, 9-70.
9. Mast EE, Weinbaum CM, Fiore AE, et al. 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 Recommendations and reports: Morbidity and mortality weekly report Recommendations and reports 2006;55:1-33; quiz CE1-4.
10. Implementation of newborn hepatitis B vaccination--worldwide, 2006. MMWR Morb Mortal Wkly Rep 2008. 57(46): p. 1249-52.
11. Terrault NA, et al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016;63(1): 261-83.
12. Terrault NA, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018;67(4):1560-99.