Hepatitis B primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

The risk of transmission of hepatitis B may be diminished by following certain measures proposed by the WHO. These include: vaccination of all infants within 24 hours of birth; vaccination of certain risk groups, such as travelers to endemic areas and healthcare workers (if these have not been vaccinated yet); avoidance of sexual contact with a person who has acute or chronic hepatitis B; and avoiding to share personal items, such as razors or toothbrushes. HBV vaccine is effective in preventing HBV infections when it is given either before exposure or shortly after exposure.

Primary Prevention

According to the WHO, the following measures should be applied to prevent infection by hepatitis B virus:

Prevention of Infection

The hepatitis B vaccine is the mainstay of hepatitis B prevention. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. The birth dose should be followed by 2 or 3 doses to complete the primary series. In most cases, 1 of the following 2 options is considered appropriate: A 3-dose schedule of hepatitis B vaccine, with the first dose (monovalent) being given at birth and the second and third (monovalent or combined vaccine) given at the same time as the first and third doses of DTP vaccine 4 doses, where a monovalent birth dose is followed by 3 monovalent or combined vaccine doses, usually given with other routine infant vaccines The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. Protection lasts at least 20 years and is possibly lifelong. All children and adolescents younger than 18 years old and not previously vaccinated should receive the vaccine if they live in countries where there is low or intermediate endemicity. In those settings it is possible that more people in high risk groups may acquire the infection and they should also be vaccinated. They include: People who frequently require blood or blood products, dialysis patients, recipients of solid organ transplantations People interned in prisons Injecting drug users Household and sexual contacts of people with chronic HBV infection People with multiple sexual partners, as well as health-care workers and others who may be exposed to blood and blood products through their work Travellers who have not completed their hepatitis B vaccination series should be offered the vaccine before leaving for endemic areas Screening of all donated blood has reduced the chance of getting hepatitis B from a blood transfusion. Mandatory reporting of the disease allows state health care workers to track people who have been exposed to the virus. The vaccine is given to those who have not yet developed the disease. The hepatitis B vaccine or a hepatitis B immune globulin (HBIG) shot may help prevent hepatitis B infection if it is given within 24 hours of exposure. Lifestyle measures for preventing transmission of hepatitis B: Avoid sexual contact with a person who has acute or chronic hepatitis B Use a condom and practice safe sex Avoid sharing personal items, such as razors or toothbrushes. Do not share drug needles or other drug equipment (such as straws for snorting drugs) Clean blood spills with a solution containing 1 part household bleach to 10 parts water Hepatitis B (and hepatitis C) viruses cannot be spread by casual contact, such as holding hands, sharing eating utensils or drinking glasses, breast-feeding, kissing, hugging, coughing, or sneezing.

Patients with chronic hepatitis B should be aware of the following:

Education and Prevention of Hepatitis B

Importance of lifestyle modifications, such as reduction of alcohol consumption Risk of transmission to others: Household memebers with negative test results for HBV serologic markers should be vaccinated. Regular sexual partners with negative test results for HBV serologic markers should be vaccinated. Casual sexual partners or unvaccinated regular sexual partners should prefer barrier protection methods. Pregnant HBsAg-positive women should inform their healthcare providers, so that Hepatitis B Immune Globulin and hepatitis B vaccine may be administered to the infant after delivery. Healthcare workers infected with hepatitis B should consult an expert review panel. In case of organ transplant, in which anti-HBc-positive organ donors are used for HBV seronegative recipients, HBV infection should be prevented with the administration of antiviral therapy. 6-12 months of prophylactic therapy may be sufficient for organ transplants, other than hepatic. For hepatic transplants, it is recommended life-long antiviral therapy.

Vaccination

Hepatitis B vaccine is the most effective tool in preventing the transmission of HBV and HDV. Vaccines are composed of the surface antigen of HBV (HBsAg), and are produced by two different methods:The natural reservoir for hepatitis B virus is man. Closely related hepadnaviruses have been found in woodchucks and ducks, but they are not infectious for humans.

• Plasma derived
• Recombinant DNA

When administered properly, hepatitis B vaccine induces protection in about 95% of recipients. HBV vaccine is effective in preventing HBV infections when it is given either before exposure or shortly after exposure. At least 85%-90% of HBV-associated deaths are vaccine-preventable.

WHO recommends that hepatitis B vaccine be included in routine immunization services in all countries. The primary objective of hepatitis B immunization is to prevent chronic HBV infections which result in chronic liver disease later in life. By preventing chronic HBV infections, the major reservoir for transmission of new infections is also reduced.The natural reservoir for hepatitis B virus is man. Closely related hepadnaviruses have been found in woodchucks and ducks, but they are not infectious for humans.

For more information on the hepatitis B vaccine, please see Hepatitis B vaccine.

Immune Prophylaxis

Hepatitis B Immunoglobulin (HBIG) is similar to conventional IG preparations except that it is prepared from plasma preselected for a high titre of anti-HBs (>100 000 IU/ml of anti-HBs):

• HBIG protects by passive immunization if given shortly before or soon after exposure to HBV.

• The protection is immediate, but it lasts only 3 to 6 months.

• HBIG is not recommended as pre-exposure prophylaxis because of high cost, limited availability, and short-term effectiveness. HBIG is generally not affordable in developing countries.

• HBIG should be given to adults within 48 h of HBV exposure.

• Maternal-neonatal transmission of HBV and the subsequent development of chronic hepatitis B in infected children has been reduced drastically, when HBIG was given to newborn babies of HBV carrier mothers in conjunction with the first dose of HB vaccine.