Vaccine Preventable Diseases
Advisory Committee on Immunization Practices (ACIP) Recommendations
• All medically stable infants weighing ≥2,000 grams without contraindications should receive the first dose of hepatitis B vaccine (trade names: Engerix-B®, Recombivax HB®) within 24 hours of birth.
• Certain infants at increased risk of acquisition of hepatitis B, such as infants born to hepatitis B-infected mothers or mothers with unknown status, should receive hepatitis B vaccine as soon as possible after birth along with a dose of hepatitis B immune globulin.
• The second dose should be administered a minimum of 4 weeks after the first dose and between 1-2 months of age. The third dose should be administered a minimum of 8 weeks after the second and 16 weeks after the first, between 6-18 months of age.
Children, Adolescents and Adults
• All children not previously vaccinated should receive the age-appropriate dose of hepatitis b vaccine, preferably at 11 or 12 years but up to 18 years of age.
• The usual schedule for adolescents is two doses separated by no less than 4 weeks, and a third dose at least 8 weeks from the second dose and 16 weeks from the first dose, and preferably 4 to 6 months after the second dose. An approved alternative schedule for adolescents 11 to 15 years of age is two 1.0-mL doses of the Recombivax HB® vaccine separated by 4 to 6 months.
• Adults at increased risk of hepatitis B infection (including sex partners or household contacts of hepatitis B infected persons; sexually active persons not in a long-term mutually monogamous relationship; persons seeking evaluation or treatment for a sexually transmitted disease; men who have sex with men; current or recent injection drug users; residents and staff of facilities for developmentally disabled persons; health care and public safety workers at risk of exposure to blood or body fluids; persons with end-stage renal disease or diabetes mellitus; HIV-infected individuals; and international travelers to countries with high or intermediate endemnicity) should be vaccinated. If using Recombivax HB® or Engerix-B®, the first two doses should be separated by at least 4 weeks and a third dose administered 4-6 months after the second dose. If using HEPLISAV-B™ vaccine, only two doses (0.5 mL each) are given one month apart, but both doses must be HEPLISAV-B™.
• Persons with chronic liver disease (including, but not limited to, those with hepatitis C virus [HCV] infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal) should also be vaccinated [1, 4-7].
For More Information
ACIP recommendations: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html
Immunization schedules: http://www.cdc.gov/vaccines/schedules/index.html
Hepatitis B Virus (HBV) is a small, double-shelled DNA virus in the Hepadnaviridae family. HBV is transmitted via mucosal exposure to infected body fluids, often during birth, sexual contact, via blood or blood exposure, needlesticks, or injection drug use . The incubation period averages 120 days. Approximately 90% of infants and 50% of adult infections are asymptomatic, and when there are symptoms, they are indistinguishable from those of other types of acute viral hepatitis. Initial symptoms include malaise, anorexia, nausea, vomiting, fever, headache, myalgia, arthralgia, arthritis and dark urine. Further symptoms such as jaundice, light or gray stools, hepatic tenderness and hepatomegaly typically last 1-3 weeks, and begin 3-10 days after the onset of most initial symptoms (1-2 days following the onset of dark urine). Most acute HBV infections result in complete recovery; however, 1-2% of cases result in fulminant hepatitis, which has a case-fatality rate of 63-93% and causes roughly 200-300 deaths in the United States annually. Up to 90% of infants infected at birth by their mothers become chronically infected, and about 25% of those chronically infected will die from cirrhosis or liver cancer. This risk of chronic infection decreases with age, to about 5% of acute infections in adults become chronic. Chronic infection is often asymptomatic until complications develop .
Hepatitis B vaccines are yeast-derived recombinant vaccines containing HBsAg protein. There are three hepatitis B vaccines used in the United States: Recombivax HB®, which is adjuvanted with aluminum hydroxyphosphate sulfate; Engerix-B®, which is adjuvanted with aluminum hydroxide; and HEPLISAV-B™, which is adjuvanted with cytosine phosphoguanine (CpG) 1018. Engerix-B® and Recombivax HB® are approved for use in all ages. HEPLISAV-B™ is only approved for use in persons aged 18 years and older, administered as two doses (0.5 mL each) given one month apart [1, 7].
There are also several combination vaccines that include hepatitis B vaccine. Hep A-Hep B (Twinrix®) is approved for use in persons over 18 years of age, administered in a three-dose series at 0, 1 and 6 months. DTaP-Hep B-IPV (Pediarix®) is approved for use at 2, 4 and 6 months of age. Pediarix® cannot be used before 6 weeks of age, but can be substituted for doses 2 or 3 of hepatitis B vaccine. Infants may also receive a fourth dose of hepatitis B vaccine as part of a combination vaccine schedule .
The Hib-Hep B combination vaccine Comvax® was discontinued in the United States in 2014 .
Vaccine Effectiveness: Over 90% of adults and 95% of children develop protective antibody responses after three doses of Recombivax HB® or Engerix-B®. These vaccines are > 95% effective at preventing clinical disease and the chronic carrier state after infection, and estimated to be 80-100% effective in preventing hepatitis B infections after completion of the series. Although antibody levels decline, immunologic memory induced from vaccination persists and serologic responders have been shown to be protective for at least 20 years. Follow-up studies of infants vaccinated at birth have revealed that many adolescents do not develop an anamnestic response (i.e. renewed rapid antibody production on a subsequent encounter with the same antigen) to a booster dose of vaccine, but there is no evidence of an increased rate of breakthrough disease and no routine booster dose has been recommended .
Studies of HEPLISAV-B™ have so far demonstrated high rates of seroprotection (90.0-100.0% of HEPLISAV-B™ recipients versus 70.5-90.2% of subjects in comparison group) .
Vaccine Safety: Anaphylaxis occurs approximately once per every 1.1 million doses of hepatitis B vaccine administered. Alopecia has been suggested to be rarely associated with hepatitis B vaccination. No causal association between any chronic illnesses and hepatitis B vaccine have been shown .
Post-licensure safety studies will be carried out by the manufacturer and CDC independently to monitor the safety of the new vaccine HEPLISAV-B™ .
Contraindications and Precautions: Severe allergic reaction (e.g. anaphylaxis) to a previous dose or vaccine component is a contraindication to further vaccination with hepatitis B vaccine. Current moderate to severe acute illness is a precaution to any vaccination .
Considerations in Pregnancy: Perinatal transmission from mother to infant at birth is very efficient. If a mother is positive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) and postexposure prophylaxis is not administered, 70%–90% of infants will become infected. If the mother is positive only for HBsAg, the risk of perinatal transmission is about 10%. Up to 90% of infant HBV infections will become chronic, and of these, 25% will die from hepatitis B related disease [1, 5, 6, 9].
Therefore, prevention of perinatal HBV infection is of the utmost importance. All pregnant women should be screened for hepatitis B surface antigen (HBsAg) and infants born to women who are HBsAg-positive should receive postexposure prophylaxis with hepatitis B immune globulin (HBIG), as well as the hepatitis B vaccine series starting at birth. Not only does hepatitis B vaccine protect against future hepatitis B infection, it is also 70%–95% effective as a postexposure prophylaxis in preventing mother-to-infant HBV transmission when the first dose is administered within 24 hours after birth followed by the completion of the three-dose series [1, 5, 6, 9]. The universal birth dose policy for hepatitis B vaccine provides an important safety net for when infected mothers are not identified during pregnancy or when there are communication errors regarding infection status. Vaccination on schedule also prevents potential HBV transmission from infected household contacts to the infant during the particularly vulnerable first months of life .
The ACIP now also recommends testing HBsAg-positive pregnant women for hepatitis B virus deoxyribonucleic acid (HBV DNA); postvaccination serologic testing for infants whose mother’s HBsAg status remains unknown indefinitely; and single-dose revaccination for infants born to HBsAg-positive women not responding to the initial vaccine series . Please refer to the most recent ACIP recommendations  as well as the American Association for the Study of Liver Diseases (AASLD) guidelines for further information on reducing perinatal HBV transmission through maternal antiviral therapy [11, 12].
Pregnancy is not a contraindication to hepatitis B vaccination. This is because the vaccine contains HBsAg, which is not infectious, and because limited data suggest that developing fetuses are not at risk for adverse events when the vaccine is administered during pregnancy [1, 6, 9].
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8. Immunization Action Coalition. Merck discontinues production of Comvax vaccine (Hib-HepB). IAC Express 2014; Issue 1136. (last accessed Oct 2018).
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10. Implementation of newborn hepatitis B vaccination--worldwide, 2006. MMWR Morb Mortal Wkly Rep 2008;57(46):1249-52.
11. Terrault NA, et al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016;63(1):261-83.
12. Terrault NA, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018;67(4):1560-99.