VHPB Recommendations on prevention and control of hepatitis B in the community. (1996)

1. Universal vaccination: the need for early cover

Universal childhood and early adolescent vaccination protects individuals from infection later in life, whether because of occupational risk, sexual activity illnesses or other behaviour such as intravenous drug use which poses a hepatitis B risk. The sooner individuals are vaccinated against hepatitis B the better. Early vaccination protects individuals from childhood infection which results in high carrier rates and chronic disease. Chronic disease is associated with serious and fatal liver cancer.

Infant vaccination programmes:
The VHPB endorses the 1991 statement of the WHO Working Group on the control of Viral Hepatitis in Europe which stated: "The routine immunisation of infants and adolescents should receive the highest priority. Hepatitis B vaccination should be integrated into the routine infant immunisation programme in all countries".

Adolescent vaccination programmes:
The Board also supports recommendation made by the WHO Global Advisory Group of the Expanded Programme on Immunisation endorsed by the World Health Assembly in 1992: "Hepatitis B vaccine should be integrated into the national immunisation programmes...in all countries by 1997. Countries with a low prevalence may consider immunisation of all adolescents as an addition or alternative to infant immunisation". Adolescent programmes should be directed at young adolescents before the age of 13, and are appropriate in countries where there are structures and resources for delivery of vaccines to young adolescents such as school health services.

Infant plus adolescent vaccination programmes:
Combined universal early adolescent and infant vaccination programmes have been shown to have the fastest impact on reducing levels of hepatitis B infection. Vaccination of young adolescents can of course stop once the first group of individuals vaccinated as infants reaches early adolescence.

High-risk strategies plus universal vaccination:
High -risk group approaches have failed to control hepatitis B infection in the general population. But it is good medical practice to protect individuals in these groups. Strategies aimed at vaccinating and changing behaviour in high-risk groups should therefore continue. However, universal vaccination programmes are also needed to eliminate hepatitis B infection, even in areas of low endemicity, because high-risk strategies alone are clearly failing. Public health officials, healthcare providers and the public need to be aware of this and take action.

2. Recommendations for maternal screening

Where screening of pregnant women for hepatitis B marker exists, it should continue, but any screening programme should cover all women rather than selected groups. Selective screening has been shown to miss many cases of hepatitis B. The VHPB recommends that, within 12 hours of birth, babies born to carrier mothers should receive specific hepatitis B immune globulin (HBIg) and the first dose of vaccine at another injection site. Where effective maternal screening programmes do not exist, the VHPB feels that resources may be better directed towards a universal vaccination programme aimed at adolescents or infants or both.

3. Combined vaccines

The VHPB supports efforts to add hepatitis B vaccination to existing infant and adolescent vaccination programmes. Hepatitis B vaccines can and should be integrated into any existing schedule. In addition, combination vaccines would be useful in hepatitis B control programmes. The VHPB advocates the development and use of combination vaccines which contain the hepatitis B component. These vaccines require fewer injections, this making them more acceptable to the public and the health care provider, and representing savings on syringes, storage, transportation, record keeping and training. In addition, it could possibly reduce the number of medical visits required. The implementation of universal hepatitis B vaccination, however, should not be delayed until such combined vaccines are available.

4. Raising awareness about the dangers of hepatitis B

The VHPB seeks to raise the awareness of health care providers about the dangers of HBV as a community health risk and about the need for hepatitis B immunisation, both for themselves and for their patients. The VHPB also realises the importance of understanding the attitudes, believes and behaviours of health care providers, health policy makers and the general public (especially the parents) when working to improve the success of universal hepatitis B vaccination programmes. The VHPB aims to produce and support educational initiatives targeted at these groups.

5. Monitoring and evaluation

The hepatitis B prevention programmes must be carefully monitored and evaluated. Updates need to be available at regular intervals.

6. Booster strategies

There are no reported cases of clinical hepatitis B or HBV carrier state in individuals who have been vaccinated successfully (³ 10 IU L antiHBs) in more than 10 years follow-up, despite the loss of detectable antibody in many individuals. Immunological memory induces a rapid anamnestic response in exposed individuals. This can abort clinical hepatitis B or the development of the carrier state. However, some clinically insignificant breakthrough infections have been reported in vaccinated individuals in whom only antiHBc seroconversion occurred. Given these data, routine administration of booster doses in universal vaccination programmes is not recommended by the VHPB.

7. Contraindications to vaccination

There are few absolute contraindications to vaccination. Still, withholding vaccination for inappropriate contraindications has been identified as an important cause of under-immunisation. For hepatitis B vaccination only severe reactions to previous doses, hypersensitivity to one of the vaccine components, and fever above 38.5 °C are considered contraindications.