HEPATITIS B

Disease risk areas
Present worldwide.

Carriage rates of HBsAg
LOW (less than 2%) in most European and North America countries (excluding Alaska and the far north of Canada)
MEDIUM (2& to 7%) in most of the Middle East, eastern Europe and Russia, the Indian subcontinent, south and central America (excluding Amazonia), north Africa, Alaska and northern Canada.
HIGH (greater than 7%)in most of Subsaharan Africa, Amazonian parts of South America and the Far East including China, Indonesia and many South Pacific islands.

Transmission
Spread is through sexual intercourse and from contaminated blood products.
It is also spread through 'blood to blood' contacts such as through injuries in playgrounds; contaminated instruments during medical, dental, acupuncture and other body piercing procedures; sharing intra-venous needles; at birth from an infected mother to her infant.

Vaccination for travellers
This should be considered for the following groups of travellers going to medium and high risk areas.
Those staying for long periods (e.g. more than 3 months) and frequent travellers.
Those at occupational risk (e.g. health care workers).
Young children mixing with locals in poor hygienic conditions.
Those with pre-exiting medical conditions who may need medical attention or surgical proceedures (e.g. if preganant).
Those who may be at sexual risk or at risk of sharing percutaneous needles.
Military personnel

ACTIVE VACCINATION
Always confirm details with manufacturer's literature

ENGERIX - Smith Kline Beecham
Type: Inactive, recombinant.
Primary course: 3 doses.
Dose: 1ml for both adults and children
Route: I/M (not buttocks)
1st interval: 1 month
2nd interval: 5 months
Accelerated schedule: 3 doses at monthly intervals with booster 12 months later.

HB-VAX - Pasteur Merieux Ages: over 15 years
Type: Inactive, recombinant.
Primary course: 3 doses.
Dosage: 1ml (see below for different preparation for children
Route: I/M (not buttocks)
1st interval: 1 month
2nd interval: 5 months
The accelerated schedule described above can also be used.

HB-VAX II PAEDIATRIC - Pasteur Merieux
Ages: Birth - 15 years)
Type: inactive
Primary course: 3
Dosage: 0.5mls (pre-filled syringe)
Route: IM (anterolateral aspect of thigh in neonates, infants and young children)
Schedule : 0, 1 and 6 months
The accelerated schedule described above can also be used.

Boosters for both adult and childrens vaccines: Duration of immunity is not yet clear but it is thought boosters will not be needed more often than 5 yearly.
If given for occupational reasons in Britain the booster interval is usually decided after antibody test.
Side effects: Occasionally soreness and redness at the injection site may appear.
Contraindications: Vaccination should be postponed in individuals suffering from a febrile illness.

HB-VAX II-40 (Pasteur Merieux).
This vaccine (introduced in October 1998) is specifically aimed at protecting pre-dialysis and dialysis patients. It contains recombinant Hepatitis B Vaccine 40mcgms/millilitre. It can be used for all ages.
Primary course: 3 doses
Intervals: 1 month between first and second doses, 5 months between second and third doses.
The accelerated schedule described above can also be used.

HYPER-IMMUNOGLOBULIN
Occasionally it can be appropriate to use hyperimmune hepatitis B immunoglobulin for short-term protection of those at "high risk".
For example: for medical or nursing personnel going to work in highly endemic areas, when there is either not enough time to give a course of active vaccine or when they are "non- responders" to previous courses of vaccination.

COMBINED HEPATITIS A AND HEPATITIS B VACCINE (Smith Kline Beecham).
For adults (TWINRIX)
This combined hepatitis A and B vaccine, introduced in 1997, can be used in adults and adolescents over 16yrs.
For For children (TWINRIX JUNIOR)
This can be used from 1 year up to and including 15 years of age.
Primary schedule: 3 doses
Schedule: 3 doses with 4 wks between 1st and 2nd doses and 5 mths between 2nd and 3rd doses.
Boosters: 10 yearly for hepatitis A. The duration of immunity after hepatitis B vaccination is not yet clear but it is thought boosters will not be needed more often than 5 yearly.

Notes:
04/11/98
Hepatitis B immunisation and the lack of any proven link with de-myelinating disease.
The World Health Organisation has issued a statement (WER 1998,73,329) expressing concern that the French Ministry of Health has suspended immunisation of teenagers and that this decision could influence the success of the international campaign to include hepatitis B immunisation in national programmes.
WHO states that 'none of the evidence gathered by WHO from numerous scientifically reliable sources supports the causal link between hepatitis B vaccine and de-myelinating disease.