NHS FORTH VALLEY Guidelines for Hepatitis B Vaccination in High Risk Groups

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1 NHS FORTH VALLEY Guidelines for Hepatitis B Vaccination in High Risk Groups Approved 01/04/2012 Version 1.0 Date of First Issue 01/04/2012 Review Date 01/02/2014 Date of Issue 01/04/2012 EQIA Yes Author / Contact Juliet Tucker/ Debbie Forbes Group / Committee Final Approval Women & Children Clinical Governance Committee Version st April 2012 page 1 of 7

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: Juliet Tucker Consultant Paediatricians NNU staff Distribution: FV Intranet NNU Change Record Date Author Change Version 28/10/10 JAT Update schedule according to comments/feedback 2.0 Version st April 2012 page 2 of 7

3 NHS Forth Valley Women & Children s Unit Hepatitis B Vaccination in High Risk Groups Table of Contents Table of Contents...3 Indications for vaccination...3 Antenatal management...4 Consent...4 Immunisation Schedule...4 Known Hepatitis B exposure (eg Maternal Hep B)...5 Adverse reactions...6 Discharge...6 Indications for vaccination All babies / children whose mothers have a history of past or present hepatitis B. Some babies will also require Hepatitis B immunoglobulin (See appropriate protocol). All babies / children born to mothers with past or present history of IV drug misuse irrespective of their mother's HBV status. All babies / children who will be a close household contact of any other person with a history of Hepatitis B infection or who has a past or current history of IV drug use. Also consider: Children living in residential care with learning difficulties where risk of biting or being bitten. Children travelling to high risk countries Children with chronic liver disease Children with chronic renal failure Children receiving regular blood products eg Haemophilia Vaccination should be offered to all those who fit these criteria. For newborns, the sooner the vaccination can be given the better. Vaccination is highly effective at preventing transmission if first dose given within 48 hours. Version st April 2012 page 3 of 7

4 Babies acquiring the virus through vertical transmission have a high chance of becoming chronically infected and so this is particularly important in those who have been exposed to maternal Hepatitis B or whose status is unknown. Flowchart: - Management of babies whose Parents have a history (past or present) of IV drug use regarding risk of Blood-Bourne Infection Antenatal management Risk of Hepatitis B and benefits of vaccination for the baby should be discussed with the mother antenatally a Department of Health information leaflet is available. For those at risk of Hepatitis B through lifestyle, antenatal screening for other blood borne infections including HIV and Hepatitis C should be completed and results documented antenatally and in baby notes after birth. Consent Consent must be obtained from a parent with parental rights or the local authority if consent to medical treatment has been granted by a court as a condition of a supervision requirement. Immunisation Schedule Hepatitis B vaccines are inactivated and so cannot cause the disease. It can be given at the same time as other vaccines but must be given in a different area, or at least 2.5cm apart if given in the same limb 1 There is evidence that the response to hepatitis B vaccine is lower in pre-term, low-birth weight babies 2. It is, therefore, important that premature infants receive the full paediatric dose of hepatitis B vaccine on schedule. Babies with a birthweight of 1500g or less, born to mothers infected with hepatitis B, should receive HBIG in addition to the vaccine, regardless of the e-antigen status of the mother. Hepatitis B immunoglobulin (HBIG) provides passive immunity to give intermediate protection after exposure until the hepatitis B vaccine becomes effective. It should be given at the same time as the hepatitis B vaccine but in the other thigh. It should be administered as soon as possible, and at least within 24h of birth. Immunisations are usually given as part of a 3 dose schedule with or without a fourth booster dose. This would only be given if known exposure or if schedule had been incomplete/out of timescales and titres low. The accelerated schedule can be used for prophylaxis if compliance is a concern. For teenagers between 11 and 15 years, a two dose schedule (at zero and six months) of the adult vaccine provides similar protection to three doses of the childhood vaccine. Administer 10 microgrammes Engerix B (0.5ml), by IM injection. Version st April 2012 page 4 of 7

5 For High Risk prophylaxis At birth At 1 month At 6 months For Hep B exposure (accelerated schedule) At birth At 1 month At 2 months Booster at 1 year if Booster at 1 year with exposure continues serology check Markers of infection / Response to vaccine Testing for markers of past or previous infection would only be clinically indicated in children of affected parents or if status is unknown in high risk groups. This should be done prior to the first vaccination. Checking antibody response following appropriately completed schedule is not routinely necessary in those vaccinated because of risk factors only. Where immunisation has been delayed beyond the recommended intervals, the vaccine course should be completed, but it is more likely that the child may become infected / have incomplete protection. In this instance, testing for HBsAg above the age of one year is particularly important. The full duration of protection afforded by hepatitis B vaccine has yet to be established 3. Levels of vaccine-induced antibody to hepatitis B decline over time, but there is evidence that immune memory can persist in those successfully immunised 4. However, recent evidence suggests that not all individuals may respond in this way 5,6. It is, therefore, recommended that individuals at continuing risk of infection should be offered a single booster dose of vaccine, once only, around five years after primary immunisation. Measurement of anti-hep B levels is not required either before or after this dose. Boosters are also recommended after exposure to the virus. Known Hepatitis B exposure (eg Maternal Hep B) * (See Hep B protocol for Hep B positive mothers) For those who are given the vaccination because of known Hep B exposure, inform parent/guardian that testing for HBsAg at one year of age will be performed. Version st April 2012 page 5 of 7

6 This will identify any babies for whom this intervention has not been successful and who have become chronically infected with hepatitis B, and will allow them to be referred for assessment and any further management. This testing can be carried out at the same time as the fourth dose is given. Adverse reactions Hepatitis B vaccine is generally well tolerated and the most common adverse reactions are soreness and redness at the injection site. Other reactions that have been reported but may not be causally related include fever, rash, malaise and an influenza-like syndrome, arthritis, arthralgia, myalgia and abnormal liver function tests. Hepatitis B Immunoglobulin (HBIG) is well tolerated. Very rarely, anaphylactoid reactions occur in individuals with hypogammaglobulinaemia who have IgA antibodies, or those who have had an atypical reaction to blood transfusion. Discharge Ensure consent is documented and whether vaccine was given. Document relevant dates for when the vaccine was given and when the immunisations are due at 1 month and 6 months of age. Ensure antenatal screening results for HepB, Hep C and HIV documented. The information should be documented in the child s notes and communicated to primary care at discharge to ensure continuity of the schedule in the community. If child is looked after i.e in foster care placement ensure correspondence sent to child s own GP which may differ from Mums. Also send copy of discharge to: Administrator - Catherine Tannahill, Looked After Children s Health Team, St. Ninians Health Centre, Mayfield St, Stirling, FK70BS. Tel: References (Guidance largely extracted from The Department of Health - The Green Book 2006 updated Nov 2010) Also see FV Guidance for infants of Hep B positive mothers (draft 2010) 1. American Academy of Pediatrics, Losonsky et al., Whittle et al., Liao et al., 1999 Version st April 2012 page 6 of 7

7 5. Williams et al., Boxall et al., 2004 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - Version st April 2012 page 7 of 7

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