HBV vaccination programs: Your questions answered
August 1, 1999 4 minutes read
HBV vaccination programs: Your questions answered
Survey respondents express common concerns
[Editor’s note: Those who responded to the recent Hospital Employee Health hepatitis B vaccination program survey posed a number of questions about policies and procedures. We asked William Bower, MD, a senior research associate with the Centers for Disease Control and Prevention’s (CDC) hepatitis branch, for the answers. Most of the information provided can be found in one of the three documents listed in the first answer.]
Q: Where can current CDC recommendations regarding hepatitis B vaccination programs for health care workers be found?
A: Updated guidelines are now in the approval process and will be issued possibly later this year. Meanwhile, current recommendations are published in several documents:
Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in health care personnel. Am J Infect Control 1998; 26:289-354.
Centers for Disease Control and Prevention. Immunization of health-care workers: Recom men dations of the Advisory Committee on Immu niza tion Practices (ACIP) and the Hospital Infe ction Control Practices Advisory Committee (HICPAC). MMWR 1997; 46 (RR-18):1-42.
Centers for Disease Control. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991; 40 (RR-13):119.
Q: To whom should hepatitis B vaccine be offered? For example, do unit secretaries who may be touching specimen containers need it?
A: Any employees who have the potential to come into contact with blood or body fluids should be encouraged to receive vaccine.
Q: What is the recommendation on testing for prevaccination titers?
A: We don’t recommend it. Pre-vaccination serology screening for previous infection is not indicated for persons being vaccinated because of occupational risk unless the hospital considers screening cost-effective.
Q: What do you recommend when employees don’t return for the second or third vaccine dose according to the recommended 0-1-6 vaccination schedule?
A: It depends on the schedule, but it shouldn’t be a problem. For maximum effectiveness, the second dose should be received one month after the first. Employees can get the second vaccine greater than a month later and the third vaccine greater than five months after that, but the maximum interval has not been established. Anecdotally, in vaccine trials it did not appear to affect efficacy as long as there was one month between the first two doses and at least four months between the second and third doses.
The recommendation for an interrupted schedule is to give the second dose as soon as the person presents, as long as at least one month has passed since the first dose. If the employee gets the second dose on time, then is lost to follow-up and doesn’t get the third dose five months later, give the third dose whenever possible after that, even if it is two years later. We consider them protected. If the vaccine schedule is interrupted, never re-initiate it.
Q: For how long does vaccination confer immunity? Any update on length of effectiveness? What about the need for booster doses?
A. We feel in 1999 that the vaccination series is good for at least 17 years because that’s what the data show so far. Of the people who were vaccinated in 1982 when the vaccine first became available, those who showed a response have not developed symptomatic disease. We recommend booster doses only when a health care worker tested after a documented exposure has low titers and you don’t know if they were ever a responder. If they were a vaccine responder, you don’t have to give any postexposure treatment. (For more postexposure recommendations, see chart, p. 90.)
The 1991 MMWR (see reference above) reports that long-term studies of healthy adults and children indicate that immunologic memory remains intact for at least nine years after vaccination and confers protection against chronic hepatitis B infection even though anti-hepatitis B surface antibody (anti-HBs) levels may become low or decline below detectability levels. That information hasn’t changed in the last eight years since the report was issued.
Q: What about postvaccination testing for titers? And what do you consider an adequate titer?
A: Greater than or equal to 10 mIU/ml is what we recommend. Postvaccination screening for anti-HBs is advised for personnel at ongoing risk for blood exposure to determine whether response to vaccinations has occurred and to aid in determining the appropriate postexposure prophylaxis or the need for revaccination. Personnel who do not respond to or do not complete the primary vaccination series should be revaccinated with a second three-dose vaccine series or evaluated to determine whether they are HBsAg-seropositive.
Revaccinated persons should be tested for anti-HBs at the completion of the second vaccine series. If they do not respond, no further vaccination series should be given, and they should be evaluated for the presence of HBsAg (possible chronic HBV infection).
Vaccine-induced antibodies decline gradually with time, but vaccine booster doses are not routinely recommended. People who respond to the initial vaccine series remain protected against clinical hepatitis and chronic infection even when their anti-HBs levels become low or undetectable. We don’t recommend that you test except one to two months and no more than six months after the last dose. That is the only time you can determine if someone is a responder.
Q: Why do schools for health care workers not require students to start and complete the vaccination series?
A: Health care workers’ risk for percutaneous or permucosal exposure to blood varies but is often highest during their professional training period. Therefore, vaccination should be completed during training in schools of medicine, nursing, dentistry, laboratory technology, and other allied health professions.
Q: A recent television program broadcast a segment claiming a connection between hepatitis B vaccine and development of multiple sclerosis. Is there any truth to this?
A: We believe that the hepatitis B vaccine is very safe. There is no scientific evidence to show any correlation between the vaccine and multiple sclerosis. Anyone who is concerned should read the articles on this Web site: www.cdc.gov/nip/ vacsafe/vaccinesafety/hottopics/hepb.htm.
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