Hepatitis B Vaccination

Hepatitis B is a serious but vaccine-preventable viral infection of the liver that is transmitted by blood from the mother to the child at birth, by contact between open wounds, through sexual contact, or contaminated blood or needles. Universal hepatitis B vaccination hopefully will one day eradicate this devastating infection that leads to the development of primary liver cancer or scarring and cirrhosis of the liver. There are an estimated 400 million people worldwide with chronic hepatitis B infection, frequently referred to as carriers, and one in four will die from liver cancer or cirrhosis, often striking the victims at the prime of their life.

The hepatitis B vaccine provides an easy and effective method for preventing HBV infection and its deadly implications including liver cancer and liver failure. The vaccination is so effective and because over 80% of liver cancer is caused by hepatitis B infection, that the World Health Organization calls the hepatitis B vaccine the first "anti-cancer" vaccine.

Indications for use of hepatitis B vaccination
If not already infected, the following categories of people should receive vaccination for hepatitis B:
  • All infants and previously unvaccinated children and adolescents aged 0-18 years
  • Sexual partners or household contacts of HBsAg-positive persons
  • Persons with multiple sexual partners
  • Injecting drug users
  • Travelers to regions of high HBV endemicity such as Asia
  • Persons with occupational exposure to blood or body fluids
  • Men who have sex with men
  • Clients and staff of institutions for developmentally disabled persons
  • Patients with chronic renal failure
  • Patients receiving clotting factor concentrates

Modified from: Centers for Disease Control and Prevention. Update: recommendations to prevent hepatitis B virus transmission - United States. MMWR 1999;48:33-35

Current Recommendation of the CDC
The CDC recommends hepatitis B vaccination of all infants, children and adolescents aged 0-18, and high-risk patients. Recent reports demonstrate a reduction in the risk of hepatocellular carcinoma in children in Taiwan (N Engl J Med 1997;336:1855-1859) with universal hepatitis B vaccination. Prevaccination testing for previous or current HBV infection is indicated in some high-prevalence groups, and post-vaccination testing to confirm the presence of anti-HBs >10 mIU/mL is useful in high-risk persons such as health care workers. Some nonresponders or partial responders (<10 mIU/mL) will respond to additional doses of hepatitis B vaccine. The duration of protection after hepatitis B vaccination is not precisely known but thought to be long-term, and thus routine booster doses of hepatitis B vaccine are not recommended.

Additional Recommendation from the Asian Liver Center
In addition, the Asian Liver Center recommends that all adults in childbearing age (men and women under 45 years of age) get vaccinated if they are not protected. All Americans, who are foreign born or are children of foreign born parents, especially Asian and Pacific Islanders, should be tested for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (HBsAb) to see if they have already become chronically infected or would benefit from hepatitis B vaccination.

Vaccination Schedule
All people, including children, adolescents, and adults, should be immunized using three doses on the following schedule, provided that they are not already chronically infected with HBV. The series can be started at any age.
  • Typical schedule: 0, 1, 6 months.
  • Hep A/Hep B Combo vaccine: 0, 1, 6 months.
  • For those who have fallen behind: Do not start the series over. Continue where the patient left behind.
  • The vaccine can provide immunity for life so no booster shots are currently recommended.

Pre- and Post-Vaccination Screening for HBV Immunity
Pre-vaccination Testing. Because 10% of API's already have HBsAg, pre-vaccination screening is necessary to:
  1. Identify people who do not know they are HBsAg positive, so they can start managing their illness. The vaccination will not provide any protection to an individual who is already infected with HBV.
  2. Reduce unnecessary vaccinations of people who have already have anti-HBs through natural infection of prior vaccination. These people are already immune.
Post-Vaccination Testing. After completing the series, most children, adolescents, and adults do nt need to be tested for hepatitis B antibodies. However, the following groups should be post-tested:
  • Infants of HBsAG+ mothers. After completion of the series at 6 months, infants should be tested at 9-15 months for HBsAG anti-HBs
  • Health care workers. Test 1-2 months after completion of the series.
  • People with HIV, hemodialysis patients, transplant recipients and sex partners of HBsAG persons: Do not start the series over. Test 1-2 months after completion of the series.
If A Patient Is Not Immune After Vaccination: Although rare, up to 5% of those who complete the vaccination series may not acquire immunity (HBsAb levels < 10mIU/ml). If immunity is not induced after completing the series, the following steps should be taken:
  1. Adminster another 3-shot series at the normal intervals using a different HBV vaccine.
  2. Test the patient again after completion of this series to make sure he/she is now immune.

Hepatitis B Vaccines
All vaccines are safe and efficacious. Protective anti-HBs levels of >10 mIU/mL develop in 95% to 99% of immunocompetent adults. Antibody levels are reduced in persons over age 40 and in immunocompromised patients, including those with chronic renal failure, human immunodeficiency virus infection and chronic liver disease.
  1. Recombivax, Monovalent HBV (Merck)
  2. Engerix-B, Monovalent HBV (GlaxoSmithKline)
    • Recombivax HB and Engerix-B vaccines can be used interchangeably and adminstered concurrently with hepattis B immune globulin (HBIG) or other vaccines.
    • Since 2000, new HBV vaccines contain no thimerosal (a mercury-containing preservative) or only trace amounts.
  3. Twinrix, Combination HAV/HBV (GlaxoSmithKline)
    • Recommended for: Adults (at least 18 years of age)at high risk of contacting either hepatitis A and hepatitis B, such as travelers to areas of high endemicity for both viruses, military personnel, men who have sex with men, injecting drug users, laboratory workers handling HAV and HBV, or persons at increased risk due to their sexual practices, and adults at risk of more severe disease with HAV or HBV infection, such as patients with chronic liver disease, are all potential candidates for combined vaccination.
  4. Pediarix, Combination HBV / diphtheria / tetanus / pertussis / polio (GlaxoSmithKline)
    • cannot be given before 6 weeks of age, but can be given at 2, 4 and 6 months to complete the HBV vaccination series. Each 0.5mL of Pediarix contains 10ug of recombinant HBsAg, 25 Lf diphtheria toxoid, 10Lf tetanus toxoid, 25ug inactivated pertussis toxin, 25 ug filamentous hemagglutinin, 8ug pertactin, 40 D-antigen Units (DU) Type 1 poliovirus, 8 DU Type 2 poliovirus, and 32 DU Type 3 poliovirus.
  5. Comvax, Combination HBV/H. influenza/N.Meningitides (Merck)
    • Infants born to HBsAg-negative or HBsAg-positive mothers should receive the birth dose of the HBV vaccine with either Engerix-B or Recombivax HB. Comvax cannot be given before 6 weeks of age, but can be given at 2, 4 and 12-15 months to complete the HBV vaccination series. Each 0.5mL of Comvax contains 5ug of recombinant HBsAg, 7.5ug Haemophilue influenzae type B polyribosylribitrol phosphate, and 125ug Neisseria meningitidis outer membrane protein complex.

    Administration Schedules and Dosing of Hepatitis B Vaccines
    Patients Schedule Engerix-B Recombivax HB
    Infants with
    HBsAg-negative mother    		 0-2, 1-4, and 6-18 mo 10 mg/0.5 mL 2.5 mg/0.5 mL
    Infants with
    HBsAg-positive mother    		 At birth*, 1-2 and 6 mo 10 mg/0.5 mL 5.0 mg/0.5mL
    Children and adolescents
    (0-19 yr)    		 0, 1-2, and 4-6 mo 10 mg/0.5 mL 5.0 mg/0.5 mL
    Alternative 2-dose regimen for adolescents
    (11-15 yr)    		 0 and 4-6 mo - 10 mg/1.0 mL
    Adults (>20 yr) 0, 1-2, and 4-6 mo 20 mg/1.0 mL 10 mg/1.0 mL
    Immunocompromised
    adults     (hemodialysis)    		 0, 1 and 6 mo 40 mg/2.0 mL 40 mg/1.0
    * within 12 hours and with hepatitis B immune globulin (HBIG)
    **1.0 mL of Twinrix contains 720 ELISA Units of inactivated hepatitis A virus and 20ug of recombinant HBsAg

    Modified from: Centers for Disease Control and Prevention. Update: recommendations to prevent hepatitis B virus transmission - United States. MMWR 1999;48:33-35.

Where to get vaccinated
Ask your doctor for the hepatitis B vaccine. Many insurance companies will cover the cost of vaccination. If you live in the San Francisco Bay Area, you can also find low-cost vaccinations at the health clinics listed here.

Go to What Every Carrier Should Know


- Copyright 2005 Asian Liver Center at Stanford University -