Appendix C

Identification and Management of Hepatitis B Surface Antigen (HBsAg)--Positive Persons

Persons with chronic hepatitis B virus (HBV) infection are at high risk for chronic liver disease and are a major reservoir of HBV infection. Foreign-born populations from Africa, Asia, and the Pacific Islands have high rates of chronic HBV infection (i.e., HBsAg prevalence of >8%). During delivery of recommended hepatitis B vaccination services (e.g., HBsAg screening of pregnant women and serologic testing to assess susceptibility), vaccination providers will identify persons who are HBsAg positive. These persons require counseling and medical management for chronic HBV infection to reduce their risk for chronic liver disease. Their susceptible household, sex, and needle-sharing contacts also should be vaccinated against hepatitis B.

Extending screening, referral, and contact vaccination services to persons identified as HBsAg positive can help prevent serious sequelae in persons with chronic infection and enhance vaccination strategies to eliminate HBV transmission. This appendix provides guidance for vaccination providers concerning identification and management of persons with chronic HBV infection. These guidelines are not intended to represent a comprehensive prevention program for persons with chronic infection.

Identification of Persons Who Are Potentially HBsAg Positive

• All foreign-born persons (including immigrants, refugees, asylum seekers, and internationally adopted children) from Africa, Asia, the Pacific Islands, and other regions with high endemicity of HBV infection (Box) should be tested for HBsAg, regardless of vaccination status.
  --- For all persons born in countries in which HBV is highly endemic who are applying for permanent U.S. residence, HBsAg screening and appropriate follow-up on the basis of HBsAg test results should be included as part of the required overseas premigration and domestic adjustment-of-visa status medical examination process; information about this process is available at http://www.cdc.gov/ncidod/dq/health.htm. HBsAg-positive persons should be considered eligible for migration and adjustment-of-visa status and counseled and recommended for follow-up medical evaluation and management in U.S. resettlement communities.
  --- In all settings that provide health care, providers should identify persons born in countries in which HBV infection is highly endemic and provide HBsAg testing and follow-up. Retesting of persons who were tested for HBsAg in other countries should be considered.
• Other persons who should be tested for HBsAg as part of vaccination services include
  --- all pregnant women (1);
  --- persons who receive prevaccination testing for susceptibility and who test positive for anti-HBc (see Appendix A, Prevaccination Serologic Testing for Susceptibility);
  --- hemodialysis patients; and
  --- nonresponders to vaccination (see Appendix A, Postvaccination Testing for Serologic Response).

Management of Persons Identified as HBsAg Positive

• All HBsAg-positive laboratory results should be reported to the state or local health department, in accordance with state requirements for reporting of chronic HBV infection; information about state requirements is available at http://www.cste.org/NNDSSSurvey/2004NNDSS/nndssstatechrreporcond2005.asp.
• HBsAg-positive persons should be referred for evaluation to a physician experienced in the management of chronic liver disease; a directory of liver specialists is available at http://www.hepb.org/resources/other_links_physician.htm. Certain patients with chronic HBV infection will benefit from early intervention with antiviral treatment, management of factors that can contribute to disease progression, or screening to detect hepatocellular carcinoma at an early stage.
• Household, sex, and needle-sharing contacts of HBsAg-positive persons should be identified. Unvaccinated sex partners and household and needle-sharing contacts should be tested for susceptibility to HBV infection (see Appendix A, Prevaccination Serologic Testing for Susceptibility) and should receive the first dose of hepatitis B vaccine immediately after collection of blood for serologic testing. Susceptible persons should complete the vaccine series using an age-appropriate vaccine dose and schedule (see Table 2 and Box 5). Persons who are not fully vaccinated should complete the vaccine series.
• Sex partners of HBsAg-positive persons should be counseled to use methods (e.g., condoms) to protect themselves from sexual exposure to infectious body fluids (e.g., semen or vaginal secretions) unless they have been demonstrated to be immune after vaccination (i.e., antibody to HBsAg concentrations of >10 mIU/mL) or previously infected (anti-HBc positive). Partners should be made aware that use of condoms and other prevention methods might reduce their risks for human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs).
• To prevent or reduce the risk for transmission to others, HBsAg-positive persons should be advised concerning the risks for
  --- perinatal transmission to infants born to HBsAg-positive women and the need for such infants to receive hepatitis B vaccine beginning at birth (1) and
  --- transmission to household, sex, and needle-sharing contacts and the need for such contacts to receive hepatitis B vaccine.
• HBsAg-positive persons should also be advised to
  --- notify their sex partners about their status;
  --- use methods (e.g., condoms) to protect nonimmune sex partners from acquiring HBV infection from sexual activity until the sex partners can be vaccinated and their immunity documented (persons should be made aware that use of condoms and other prevention methods might reduce their risks for HIV and other STDs);
  --- cover cuts and skin lesions to prevent spread through infectious secretions or blood;
  --- refrain from donating blood, plasma, tissue, or semen (organs may be donated to HBV-immune or chronically infected persons needing a transplant; decisions about organ donation should be made on an individual basis); and
  --- refrain from sharing household articles (e.g., toothbrushes, razors, or personal injection equipment) that could become contaminated with blood.
• To protect the liver from further harm, HBsAg-positive persons should be advised to
  --- avoid or limit alcohol consumption because of the effects of alcohol on the liver;
  --- refrain from taking any new medicines, including over-the-counter and herbal medicines, without consulting with their health-care provider; and
  --- obtain vaccination against hepatitis A if chronic liver disease is present (2).
• When seeking medical or dental care, HBsAg-positive persons should be advised to inform those responsible for their care of their HBsAg status so that they can be evaluated and their care managed appropriately.
• Other counseling messages include the following:
  --- HBV is not spread by breastfeeding, kissing, hugging, coughing, ingesting food or water, sharing eating utensils or drinking glasses, or casual contact.
  --- Persons should not be excluded from work, school, play, child care, or other settings on the basis of their HBsAg status, unless they are prone to biting (3).
  --- Involvement with a support group might help patients cope with chronic HBV infection. Information about support groups is available at http://www.hepprograms.org/support/hepb.asp and http://www.hepb.org/patients/support_groups.htm.

References

1. CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). Part 1: immunization of infants, children, and adolescents. MMWR 2005;54(No. RR-16).
2. CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No. RR-7).
3. Shapiro CN, McCaig LF, Gensheimer KF, et al. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 1989;8:870--5.

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Date last reviewed: 11/21/2006