Hepatitis B vaccination: How to reach risk groups (2001)

Injecting drug users (IDUs)

• Hepatitis B vaccination of injecting drug users, ideally as soon as possible after the start of their drug use, is recommended.
• Injecting drug users should undergo pre-vaccination testing for serological markers of HBV infection.
• If chronic infection is diagnosed, referral of IDUs to individual care services for counselling and treatment, and referral of the IDU’s household contacts and sex partners to preventive services is recommended.
• Injecting drug users, especially those known to be infected with HIV, should be subject to follow-up testing for anti-HBs after completion of their vaccination series, and to counselling if they do not respond to the vaccination. The importance of communicating the test results to clients and         to their regular health care provider is recognised.
• A one-stop service integrating multiple viral hepatitis prevention services (such as prevention counselling, screening for HBV / HCV and risk-based HAV, and hepatitis B / hepatitis A vaccination) with HIV and sexually transmitted infections services, drug rehabilitation programmes, and other drug-related services, should be established.
• The establishment of needle-exchange programmes, as an efficient means of preventing HBV infection and other blood-borne infections, is recommended.
• The client’s anonymity should be guaranteed and his or her identity known only by a unique code number.

Health care and other workers with occupational risks for hepatitis B

• The level of risk of HBV infection among health care workers, trainees, and those in related occupations is dependent upon the frequency of their percutaneous or permucosal exposure to blood or other body fluids.
• As a consequence, hepatitis B vaccination is recommended for the following groups: (1) Health care workers with frequent exposure to blood or other body material; (2) Students or trainees upon their acceptance to schools of medicine, dentistry, nursing, laboratory technology, or related areas, prior to their first potential contact with blood in a professional setting; (3) Interim health care workers, all the more so since this group is less subject to monitoring than health care workers with a permanent appointment.
• Many other occupational groups face the risk of exposure to blood or other body fluids and are therefore at risk of hepatitis B virus infection. Risk assessment should be performed on the basis of: (1) The prevalence of markers of past or current HBV infection in such groups; (2) The reported frequency of exposure to blood or other body fluids in these groups, taking geographical differences in endemicity into account.
• The need to consider vaccination strategies is recognized for groups of individuals with: (1) A higher reported prevalence of hepatitis B (e.g., tattooists); (2) Firemen, policemen, waste disposal workers, and other utility workers, who are potentially at risk of frequent exposure to blood or other body fluids, despite the fact that the prevalence of HBV markers in these categories is not higher than in the general population.
• A compilation of all bibliographic information on diseases that may be contracted as a result of performing other specific tasks would be most valuable when considering additional risk-group recommendations and riskassessment criteria.

Sex workers

• Sex workers include all persons who provide sex for money or other forms of remuneration. Sex workers are at occupational risk of sexually transmitted infections, including hepatitis B. For this group, see also the conclusions below for ‘Persons who engage in unsafe sexual behaviour.’
• Routine hepatitis B immunisation of all sex workers is recommended, irrespective of their legal status.
• Hepatitis B immunisation should be free of charge for this group, because many sex workers are not covered by health insurance and have only limited access to health care services.
• It is recognised that special attention should be given to: (1) Vaccination programmes adapted to the needs of this group; (2) Health education messages addressed to sex workers and their clients; (3) Confidentiality and appropriate counselling; (4) Anonymity achieved, e.g., by assigning a unique code number to the sex worker; (5) Promotion of outreach programmes and accelerated vaccination schedules, to guarantee higher vaccination coverage.

Persons who engage in unsafe sexual behaviour

• Hepatitis B vaccination is recommended for all adolescents and adults who engage in unsafe sexual behaviour. These groups include: (1) Heterosexuals having sexual contact with HBV infected persons or with multiple partners; (2) Men who have sex with men; (3) Persons attending sexually transmitted infections clinics; (4) Sex workers.
• A one-stop service should be established integrating multiple viral hepatitis prevention services (such as prevention counselling, selective screening for HBV or HCV, and hepatitis B vaccination) together with HIV and sexually transmitted infections services.
• Pre-vaccination screening of sexually active homosexual and bisexual men is recommended.
• Persons who engage in unsafe sexual behaviour should be subject to follow-up testing for anti-HBs after completion of their vaccination series, and to counselling if they do not respond to the vaccination.
• If chronic hepatitis B infection is diagnosed, referral of clients to individual health care services for counselling and treatment, and referral of the clients’ household contacts and sex partners to preventive services is recommended.
• The importance of the expansion of outreach programmes and the integration of vaccination and information programmes (e.g., for MSM) into non-clinical sites is recognised.

Household and other social contacts of persons with HBV infection

• Persons who have casual contact with acute hepatitis B patients or chronic HBsAg carriers at schools and offices are at low risk of catching HBV infection.
• Hepatitis B vaccination is not recommended for these persons unless in special circumstances, such as the occurrence of behavioural problems (biting or scratching) or medical conditions (severe skin disease) that might facilitate transmission.
• Some European countries recommend vaccination of daycare children and staff where they have contact with highrisk children.
• Vaccination of all household contacts of persons identified as acute hepatitis B patients or chronic HBsAg carriers is recommended.

Pregnant women and at-risk neonates

• In general, where universal screening of pregnant women for HBsAg exists, countries may wish to continue such screening programmes.
• Women who present for delivery without having been screened during their pregnancy should be tested immediately, and their newborns vaccinated within twelve hours after birth, irrespective of the screening test results.
• Infants born to mothers who are HBsAg-positive should receive the hepatitis B vaccine within 12 hours (and certainly not later than 24 hours) after birth. As no sufficient data supporting the additional value of administering HBIg at birth are available, this procedure is not recommended. This point of view is, however, not intended to promote modification of currently implemented national policies.
• Efficient implementation of universal screening procedures for pregnant women and vaccination of newborns requires: (1) Awareness among public health authorities, health care providers, and the general public of the importance of prevention of HBV infection; (2) A well-organised structure; (3) Trained personnel; (4) Good communication; (5) Sufficient resources and supplies (needles, vaccines, etc.).
• In general, where maternal screening programmes do not exist, the available resources may be better directed towards universal neonatal immunisation programmes.
• Control of perinatal transmission can be achieved if the first dose of vaccine is delivered at birth.

Haemodialysis patients and patients receiving blood or blood products

• Screening for hepatitis B markers in blood donors is recommended.
• Pre-vaccination testing for hepatitis B markers in patients who have already received multiple blood transfusions is recommended.
• Vaccination of the following groups is recommended: (1) Haemophiliacs and those frequently receiving blood or blood products; (2) Haemodialysis patients and candidates for haemodialysis, who should be vaccinated early in the course of their renal disease; (3) Transplant patients and candidates for transplant.
• These patients should be subject to follow-up testing for anti-HBs after completion of their vaccination series, and to counselling if they do not respond to the vaccination. Booster vaccination is recommended for all of them, to maintain protective levels of antibody.
• HBsAg-positive haemodialysis patients and haemodialysis machines should be isolated.
• Staff in haemodialysis units should be vaccinated prior to their first contact with haemodialysis patients.
• Patients receiving clotting-factor concentrates should receive subcutaneous hepatitis B vaccination, as soon as possible after diagnosis of their clotting disorder.

Prisoners and prison staff

• Common objectives should form the basis for hepatitis B prevention programmes within European prisons.
• Hepatitis B vaccination for all inmates upon entry into prisons or correctional facilities is recommended.
• Vaccination policies that link vaccination of prison staff and prisoners in order to achieve higher vaccine uptake levels should be considered.
• The introduction of accelerated immunisation schedules with the aim of achieving higher vaccine uptake levels among prisoners is recommended.
• Post-vaccination anti-HBs levels among prisoners and staff should be tested and recorded.
• Inmates injecting drugs should be permitted access to drug rehabilitation programmes.
• Confidential computerised records should be introduced.

Travellers

• Hepatitis B is of intermediate or high endemicity in all African countries, Latin America, Eastern Europe, most parts of Asia (except Japan), the Pacific Islands, and Arctic regions.
• Travellers to such countries are at risk of HBV infection, particularly through sexual transmission and through percuta- neous transmission, via needle sharing, blood transfusion, injections, acupuncture, tattooing, etc. Travel to these areas provides an ideal catch-up opportunity for hepatitis B vaccination.
• Hepatitis B vaccination of the following groups or individuals when travelling to areas with intermediate or high endemicity is recommended: (1) Travelling health care workers; (2) Young children who will be in day-care or residential settings; (3) Travellers likely to engage in sexual or needle-sharing activities; (4) Travellers who may need to undergo medical or dental procedures; (5) Travellers planning to undergo invasive cosmetic procedures; (6) Other travellers staying in areas of intermediate or high endemicity for more than one month, and frequent travellers making shorter trips to these areas.

References

Viral Hepatitis Prevention Board. Hepatitis B vaccination: How to reach risk groups. Viral Hepatitis Prevention Board meeting, Ghent, Belgium, March 15-16, 2001. Viral Hepatitis

2001; 10.1.