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CDC Updates Guidance for Hepatitis B Vaccination of Health-care Providers

The U.S. Centers for Disease Control and Prevention (CDC) has published updated guidance for evaluating and ensuring protection against hepatitis B virus (HBV) for health-care workers, as well as post-exposure prophylaxis recommendations for those without adequate vaccine protection.

The guidelines, published in the December 20, 2013, edition of the CDC's MMWR Recommendations and Reports, cover people working, training, or volunteering in health-care settings -- a group that increasingly includes individuals previously vaccinated against HBV as part of routine infant immunization (recommended since 1991) or catch-up adolescent vaccination (recommended since 1995).

The Advisory Committee on Immunization Practices recommends HBV vaccination for all health-care providers "with reasonably anticipated risk for blood or body fluid exposure." ACIP advises that at-risk providers should undergo serologic testing for antibodies against hepatitis B surface antigen (anti-HBs) 1-2 months after the last injection in the 3-dose series to determine if they are adequately protected, indicated by an anti-HBs level >10 mIU/mL.

According to the new guidance, providers who have not yet received complete vaccination should do so as soon as possible. Trainees should complete the vaccine series before the potential for exposure with blood or body fluids, "as higher risk has been reported during professional training."

People who were vaccinated years before they were hired as health-care providers or entered training, but who did not previously receive serological testing, "might undergo anti-HBs testing" to ensure they have adequate antibody levels. Once someone has been completely vaccinated and achieved an antibody level >10 mIU/mL, they are considered to have long-term protection and do not need further testing.

Individuals who have not had the complete vaccine series should receive the missing doses, and there is no harm in receiving extra doses if documentation of the complete series is unavailable. Minimum dosing intervals are 4 weeks between the first and second dose, 8 weeks between the second and third dose, and 16 weeks between the first and third dose. People who receive the complete vaccine series but do not achieve anti-HBs levels of >10 mIU/mL should receive 2 or 3 additional doses.

"All health-care providers should adhere to infection-control guidelines and follow Standard Precautions, including the use of engineering and work-practice controls, to reduce the risk for blood or body fluid exposure," the guidance states. All providers -- including those with adequate vaccine protection -- should immediately report blood or body fluid exposures.

Wounds and skin sites that have come in contact with blood or body fluids should be washed with soap and water, and mucous membranes should be flushed with water. Exposed providers thought to be susceptible to HBV infection should receive hepatitis B immune globulin (HBIG) and a dose of HBV vaccine as soon as possible after exposure. No post-exposure management is needed for providers who have been completely vaccinated and have adequate antibody levels.

Finally, health-care providers who are HBsAg positive should be counseled about how to prevent HBV transmission to others and referred for further evaluation. "Chronic hepatitis B infection in itself should not preclude the practice or study of medicine, surgery, dentistry, or allied health professions," according to the guidelines.

The full guidance, including more detailed recommendations for providers with incomplete vaccination, inadequate antibody response, or missing documentation, is available online.

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Reference

S Schillie, TV Murphy, M Sawyer, et al. CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management. MMWR Recommendations and Reports 62(RR10):1-19. December 20, 2013.