Preventing Hepatitis B in the United States: ACIP's Recommendations in Brief

Hepatitis B virus (HBV) spreads through blood and sexual contact. People with chronic infection are at higher risk of cirrhosis and liver cancer and need medical care. This report from the Advisory Committee on Immunization Practices (ACIP) and CDC gathers and updates the national recommendations for preventing HBV infection.

What's new in this update

• Every medically stable infant weighing at least 2,000 grams gets the first vaccine dose within 24 hours of birth — and the old wording allowing the birth dose to wait until after hospital discharge is removed.
• Pregnant women who test positive for hepatitis B surface antigen (HBsAg) are also tested for HBV DNA, to guide antiviral therapy.
• Infants whose mother's status stays unknown for good — for example, an infant safely surrendered after birth — get postvaccination testing.
• Infants of HBsAg-positive mothers who don't respond to the first series get a single revaccination dose, then retesting.
• People with chronic liver disease — including hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or ALT or AST levels more than twice the upper limit of normal — should be vaccinated.

The virus

• HBV is highly infectious, can spread without visible blood, and survives on surfaces for at least 7 days.
• It spreads through puncture or mucous-membrane contact with infectious blood or body fluids — blood above all, and also semen and vaginal fluids. Breast milk is unlikely to transmit it, so infection is no reason not to breastfeed.
• Among adults, the main routes are injection-drug use and sex; it can also pass through shared toothbrushes or razors, and in households, schools and child care.
• Incubation: on average 60 days to abnormal liver tests, 90 days to jaundice. Infants, children under 5 and people with weakened immunity usually have no symptoms; 30%–50% of older children and adults do.
• Chronic infection follows in 80%–90% of people infected as infants, 30% infected before age 6, and under 1%–12% infected later. About 25% of those chronically infected in childhood, and 15% after, die early of cirrhosis or liver cancer.
• There is no specific treatment for acute infection; chronic infection can be managed with monitoring and antivirals.

Figure 1. Incidence of hepatitis B in the United States, 1980–2015: a steep fall after the first vaccine recommendations of 1982. Figure from CDC's report.

The situation in 2015

• 3,370 acute cases were reported; counting under-reporting, about 21,900 new infections occurred.
• The reported rate fell 88.5%, from 9.6 per 100,000 in 1982 to 1.1 in 2015, though it was fairly flat in 2010–2015. It was highest at ages 30–39 and lowest at 19 and under (0.02), likely thanks to infant vaccination.
• In Kentucky, Tennessee and West Virginia, acute infections rose 114% in 2009–2013, tied to injection-drug use.
• About 850,000 people live with HBV, and possibly as many as 2.2 million; foreign-born people account for about 95% of newly reported chronic infections.
• Coverage: about 88% of commercially insured and 84% of Medicaid-enrolled pregnant women are tested; 94.9% of exposed infants get prophylaxis within 12 hours; but the birth dose reaches only 71.1% of infants (target 85%), and just 64.7% of health care personnel have had 3 or more doses (target 90%).

Pregnancy and newborns

• Test every pregnant woman for HBsAg early in every pregnancy, even if vaccinated or tested before. Test positive women for HBV DNA; the American Association for the Study of Liver Diseases suggests antiviral therapy when it is above 200,000 IU/mL. Refer them to the local Perinatal Hepatitis B Prevention Program, and send their lab report to the delivery hospital.
• Women not tested, with clinical hepatitis, or at high risk should be tested on admission for delivery.
• Infants of HBsAg-positive mothers: HepB vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth, in different limbs; finish the series (last dose not before 24 weeks); test for anti-HBs and HBsAg at 9–12 months. An infant with anti-HBs ≥10 mIU/mL is protected; one below gets one more dose and a retest, then two more doses if still low. With this prophylaxis, only 0.7%–1.1% of such infants become infected. They may breastfeed right away.
• Mother's status unknown: test her at once. Infants ≥2,000 g get the vaccine (no HBIG) within 12 hours, and HBIG by day 7 if she proves positive; infants under 2,000 g get both within 12 hours.
• All infants: the series starts at birth as a safety net. Stable infants ≥2,000 g born to negative mothers get dose one within 24 hours; smaller ones at discharge or 1 month. Where childhood infection is or was common — Alaska Natives, Pacific Islanders, immigrant families from Asia, Africa and other endemic regions — finish by 6–12 months.

Figure 2. Blood markers over time in acute hepatitis B with recovery. Figure from CDC's report.

Children, adolescents and adults

• Everyone under 19 who hasn't been vaccinated should be, at any age.
• Adults at risk should be vaccinated — and anyone who asks for protection, without having to name a risk. At risk:
• • sex: partners of HBsAg-positive people, people with more than one partner in 6 months, people seeking STI care, and men who have sex with men;
  • blood: people who inject drugs; household contacts of infected people; residents and staff of facilities for people with developmental disabilities; health care and public safety workers exposed to blood; dialysis patients; people with diabetes under 60 (and 60 or older at the doctor's discretion);
  • others: travelers to countries where HBsAg prevalence is 2% or more, people with hepatitis C, chronic liver disease or HIV, and incarcerated people.
• Pregnant women at risk should be vaccinated.
• In settings where many adults are at risk — drug treatment programs, prisons, STI and HIV services, needle exchanges, homeless shelters — offer the vaccine to all unvaccinated adults, with standing orders.
• Delivery hospitals should have standing orders and electronic reminders for the birth dose and for exposed infants; states and localities should run case management for every HBsAg-positive pregnancy.

How well the vaccine works

A full series protects about 95% of healthy infants, about 95% of adolescents, and more than 90% of healthy adults under 40 — falling to 75% by age 60. Smoking, obesity, diabetes, chronic illness and weakened immunity lower the response. Protection from a completed series appears to last 30 years or more, even as antibody levels fall. Given alone, the vaccine is 75% and HBIG 71% effective against mother-to-child spread; together, 94%.

Side effects are mostly sore arms and mild fever or headache; anaphylaxis occurs in about 1.1 per million doses.

Health care workers

CDC's guidance also covers testing health care personnel before and after vaccination and postexposure prophylaxis after a needlestick or other exposure, depending on the worker's vaccination and antibody status and the source patient's HBsAg status.

Figure 3. Evaluating health care personnel vaccinated in the past who never had their antibody level checked. Figure from CDC's report.

Sources

Based on Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, Ward JW, Nelson NP, "Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices," MMWR Recommendations and Reports, volume 67, Centers for Disease Control and Prevention; a work of the United States government in the public domain. This page summarizes the report's main recommendations; the report itself gives the full schedules, dosing and postexposure tables.