Controlling Spread of Hepatitis B

Table of Contents

A. Isolation and Quarantine Requirements

There are no isolation restrictions or quarantine requirements for patients with HBV, except for exclusion from organ and blood donation. Patients should also be provided with counseling to modify activities to prevent further transmission.

B. Protection of Contacts of a Case

Immunization of contacts: Products available for postexposure prophylaxis include hepatitis B immune globulin (HBIG) and hepatitis B vaccine.

  1. Infants born to HBsAg-positive mothers should be treated as follows:
    • Give HBIG (0.5 ml IM) and hepatitis B vaccine (0.5ml IM) according to the following:

      • First hepatitis B vaccine: Birth (within 12 hours)

      • HBIG1: Birth (within 12 hours)
        Give HBIG (0.5ml IM) simultaneously with, but at a different site from, the first dose of hepatitis B vaccine.

      • Second hepatitis B vaccine: 1–2 months

      • Third hepatitis B vaccine: 6 months

    • Screen the infant for HBsAg and anti-HBs 1 to 2 months and after the third dose of hepatitis B vaccine, when the child is at least 9 to 15 months of age, to monitor the success or failure of the immunization. If HBsAg is not present and anti-HBs antibody is present, children can be considered protected.

    • Infants who do not respond to the initial vaccine series (anti-HBs-negative) and are not HBsAg-positive should be given a second 3-dose series of hepatitis B vaccine (same schedule as initial series) and be re-screened at 1 to 2 months after the last dose.

    • Infants weighing less than 2,000 grams (4.4 lbs) should receive single-antigen hepatitis B vaccine (birth dose) and HBIG within 12 hours of birth, administered at different injection sites.

    • For preterm infant weighing less than 2,000 grams, the initial vaccine dose (birth dose) should not be counted as part of the vaccine series because of the potentially reduced immunogenicity of hepatitis B vaccine in these infants.

    • The second dose of HBV vaccine should be given when the infant is chronologically one month of age regardless of weight.The third dose should be administered one month following the second dose, and the fourth dose should be given six months following the second dose. Thus, a total of four doses of HBV vaccine are recommended in this circumstance.

    • Infants who become HBsAg-positive should be referred to a pediatric hepatologist for follow-up and the parents should be counseled. Since HBV infection is a reportable disease, the HBsAg-positive infant should be reported to Iowa Department of Public Health.

  2. Infants born to mothers whose HBsAg status is not known should be treated as follows:

    • The hepatitis B vaccine should be given within 12 hours of birth while awaiting HBsAg test results on the mother. If the mother is determined to be positive, the infant should receive HBIG as soon as possible, within 7 days of birth. This child should then complete the 3-dose hepatitis B vaccination series according to the table in Section 3) B. The child should then be screened for HBsAg and anti-HBs at 9 to 15 months of age, as described in Section 3) B above.

    • If the mother is determined to be HBsAg-negative, the infant should complete the 3-dose hepatitis B vaccine series according to ACIP recommendations, as in chart above.

    • Infants weighing less than 2,000 grams (4.4 lbs) should receive hepatitis B vaccine (birth dose) and HBIG within 12 hours of birth if the mother’s status is not determined within that timeframe.

  3. Unvaccinated infants exposed to a primary caretaker with acute hepatitis B should receive HBIG (0.5 mL) and should initiate and complete the 3-dose hepatitis B vaccine series according to the table above as soon as possible. Infants who have already started the vaccine series do not need HBIG, and should complete the vaccination series on schedule.
  4. Sexual contacts of a person with acute hepatitis B, if susceptible, should receive a single dose of HBIG (0.06 mL/kg), if the HBIG can be given within 14 days of the last sexual exposure. In addition, sexual contacts should initiate and complete a 3-dose series of hepatitis B vaccine according to the table in Section 3) D. 
  5. Sexual contacts of persons with chronic hepatitis B, if susceptible, should initiate and complete the 3-dose series of hepatitis B vaccine according to the table in Section 3) D.
  6. Nonsexual household contacts of a person with acute hepatitis B, if susceptible, who have had a blood exposure to the index patient (such as sharing toothbrushes or razors) should receive a single dose of HBIG (0.06 mL/kg) and should initiate and complete the 3-dose series of hepatitis B vaccine according to the table in section 3) D.  The 3-dose hepatitis B vaccination series should also be considered for contacts who do not have a blood exposure; children and adolescents, especially, should be vaccinated according to the table in Section 3) D.
  7. All household contacts, including infants, of persons with chronic hepatitis B, if susceptible, should initiate and complete the 3-dose series of hepatitis B vaccine according to the table in Sections 3) D. 
  8. Persons with percutaneous or mucous membrane exposures to either an acute or chronic case, if susceptible, should receive postexposure prophylaxis according to the table below.

Recommended Post-exposure Prophylaxis for Percutaneous or Permucosal Exposure to Hepatitis B Virus

Vaccination status of exposed person

 Treatment when source is found to be:    
 

HBsAg(1)-positive

HBsAg-negative

Unknown or not tested

Unvaccinated

Administer 1 dose of HBIG(3) and initiate hepatitis B vaccine series

Initiate hepatitis B vaccine series

Initiate hepatitis B vaccine series

Previously vaccinated:
Known responder(2)

No treatment

No treatment

No treatment

Previously vaccinated:
Known non-responder

 2 doses of HBIG, or 1 dose of HBIG and initiate revaccination(4)

No treatment

If known high-risk source, treat as if source were HBsAg-positive
Previously vaccinated:
Response unknown

Test exposed person for anti-HBs(5)

  • If adequate, no treatment
  • If inadequate, 1 dose of HBIG and a vaccine booster dose(6)

No treatment

Test exposed person for anti-HBs(5)

  • If adequate, no treatment
  • If inadequate, vaccine booster dose(6)

Table Footnotes

  1. Hepatitis B surface antigen.
  2. Responder is defined as a vaccinated person with adequate levels of serum antibody to HBsAg (i.e. anti HBs > 10 mIU/mL).
  3. Hepatitis B immune globulin; dose 0.06 mL/kg, intramuscularly.
  4. Persons known not to have responded to a 3-dose vaccine series and to revaccination with 3 additional doses should be given 2 doses of HBIG (0.06 ml/kg), one dose as soon as possible after exposure and the second 1 month later.
  5. Adequate serum antibody response to hepatitis B surface antigen is > 10 mIU/mL.
  6. The person should be evaluated for antibody response after the vaccine booster dose. For persons who received HBIG, anti-HBs testing should be done when passively acquired antibody from HBIG is no longer detectable (e.g., 4–6 mo.); if they did not receive HBIG, anti-HBs testing should be done 1–2 months after the vaccine booster dose. If anti-HBs is found to be inadequate (< 10 mIU/mL) after the vaccine booster dose, 2 additional doses should be administered to complete a 3-dose revaccination series.

Table adapted from: American Academy of Pediatrics. Red Book 2006: Report of the Committee on Infectious Diseases, 27th Edition. Illinois, American Academy of Pediatrics, 2006:302.

C. Managing Special Situations

School and Child care

The risk of transmission of HBV in school and child care settings has always been very low. This risk is now even lower because the proportion of susceptible children is decreasing as requirements for hepatitis B immunization for entry into kindergarten have been implemented. To prevent the transmission of hepatitis B and other bloodborne disease in these settings, however, the following guidelines should be followed:

Primary prevention: Ensure compliance with all hepatitis B immunization requirements. Vaccination is also recommended for unvaccinated classmates of hepatitis B carriers who behave aggressively (e.g., biting) or who have medical conditions, such as open skin lesions (e.g., generalized dermatitis or bleeding problems), that increase the risk of exposing others to infectious blood or serous secretions.

Secondary prevention: Persons exposed to potentially infectious blood or other body fluids should be treated according to the guidelines for “Postexposure Prophylaxis for Percutaneous or Permucosal Exposure to Hepatitis B Virus” outlined in the table above. However, in the case of a bite by a person whose hepatitis B status is unknown, it is unlikely that it will result in transmission and blood testing is not recommended for either biter or victim. The risk of HBV acquisition when a susceptible child bites an HBV carrier is not known. However, most experts would not give HBIG to the susceptible biting child who does not have oral mucosal disease when the amount of blood transferred is small.

Notification: Parents may wish to inform the school nurse or child care program director about a child who is a known hepatitis B carrier to allow for proper precautions and assessment of behavior issues that could facilitate transmission. However, this is not necessary since policies and procedures to manage exposure to blood or blood-containing materials should already be established and implemented. Parents of other children attending the school/child care do not need to be informed.

Exclusions: Adults and children ill with acute hepatitis B should stay home until they feel well, and fever and jaundice are gone. There is no reason to exclude a person with hepatitis B from employment or attendance once they have recovered from acute infection. Admission of a known hepatitis B carrier with specific risk factors, such as biting, open rashes or sores that can’t be covered or bleeding problems should be assessed on an individual basis by the child’s doctor, school/child care and responsible public health authorities. Because these children pose a risk to others in child care, consideration may be given to exclusion from child care until the aggressive behavior ceases or until all contacts have been vaccinated. However, as the proportion of children who are immunized over time has increased , concern about bites and HBV transmission has also decreased.

Prevention Guidelines: Whether or not individual hepatitis B carriers have been identified, it is important that school staff receive regular training on the prevention of bloodborne disease. Personnel should be educated about Standard Precautions for handling blood or blood-containing materials. All students should receive age-appropriate instruction regarding the potential dangers of contact with other people’s blood and other body fluids. Some Standard Precautions include:

  • Follow all procedures for handwashing and cleanliness.
  • Always treat all blood as potentially dangerous fluid and observe universal precautions, including using disposable gloves when cleaning or removing blood or body fluid spills.
  • Do not permit sharing of personal items that may become contaminated with blood or body fluids, such as toothbrushes, eating utensils, etc.
  • Cover open skin lesions.
  • Place disposable items contaminated with blood or body fluids in plastic bags in covered containers.
  • Store contaminated clothing or washable items separately in plastic bag, and send them home with the owner for proper cleaning.
  • Wash and sanitize surfaces of contaminated objects with a dilute solution of 1/4 cup household bleach in 1 gallon of water (1:100 dilution) applied for at least 30 seconds, made up on a daily basis, or disinfect objects by boiling objects for 10 minutes.
  • Supervise closely to discourage and prevent aggressive behavior.
  • Provide age-appropriate education to adolescents and young adults about prevention of sexually transmitted diseases, including hepatitis B.

D. Reported Incidence Is Higher than Usual/Outbreak Suspected

If the number of reported cases in your city/town is higher than usual, or if an outbreak is suspected, investigate clustered cases in an area or institution to determine source of infection. If evidence indicates a common source, applicable preventive or control measures should be instituted. Consult with an epidemiologist at the Center for Acute Disease Epidemiology at (800) 362-2736 for assistance in investigation and the implementation and recommendation of other control measures.

E. Preventive Measures

General control and prevention measures include implementing all hepatitis B immunization requirements and recommendations, as described below.

Pre-exposure Prophylaxis: The Iowa Department of Public Health recommends hepatitis B vaccine for the following groups:

Newborns

All newborns should receive monovalent hepatitis B vaccine soon after birth and before hospital discharge.

Following the birth dose, the hepatitis B series should be completed with either monovalent hepatitis B or a combination vaccine containing hepatitis B. The second dose should be administered at 1-2 months of age. The final dose should be administered at 6 months of age. Administering 4 doses of hepatitis B vaccine is permissible (e.g., when combination vaccines are administered after the birth dose).

Routine Schedule for Infant Hepatitis B Vaccination
Dose

Usual Age

Minimum Interval
1 Birth - 2 months —
2

1–2 months

1 month
3

6 months

2 months(1)
and 4 months from 1st dose
Table Footnotes

  1. Do not administer before 6 months of age

Children and adolescents 18 years or younger

State Immunization Requirements: Hepatitis B vaccine is required for all children who enroll in kindergarten if born on or after July 1, 1994.

Adults over 18 who are at risk

Adults at risk for HBV infection include:

  • People who have more than one sex partner in 6 months
  • Men who have sex with other men
  • Sex contacts of infected people
  • People who inject illegal drugs
  • People whose jobs expose them to human blood (The Occupational Safety and Health Administration (OSHA) of the US Department of Labor has issued a regulation requiring employers of workers at risk for occupational exposure to HBV to offer HBV immunization to these employees at the employer’s expense)
  • Household contacts of persons with chronic HBV infection
  • Hemodialysis patients

Routine Schedule for Adolescent & Adult Hepatitis B Vaccination
Dose Usual Interval

Minimum Interval

1

 — —
2 1 month

4 weeks
3

5 months

 8 weeks *
Table Footnotes

* Third dose must be separated from first dose by at least 16 weeks

Hepatitis B vaccine is produced by 2 manufacturers; both vaccines are available in pediatric and adult formulations.

  • Birth through 19 years (pediatric formulation)
  • Adults (> 20 years of age) (adult formulation)

Doses given at less than the minimum intervals should not be counted as part of the vaccination series. Do not restart series, no matter how long since previous dose.

For adults and children with normal immune status, booster doses of vaccine are not recommended, nor are routine serologic testing to assess immune status of vaccinees indicated.

Iowa Dept. of Public Health, Reviewed 7/15