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home - Liver - Hepatitis B - Hepatitis B Vaccination Written by Dr Sebastian Zeki
Knowledge


Understands the serological interpretation categorisation and
investigation of patients with chronic hepatitis B and/or C with
particular emphasis on the need for treatment and surveillance

Recognises the particular populations at risk
Aware of national and international agreed guidelines on viral
hepatitis management and use of interferon and antiviral drugs

Aware of hepatitis B reactivation in the context of immunosuppression
Skills
Uses appropriate diagnostic modalities including serology
genotyping viral load measurements liver biopsy and related
investigations

Monitors anti-viral and immunomodulatory therapies with appropriate
investigations

Behaviours
Communicates effectively with patients and relatives in the context of
viral liver disease and underlying social and psychological risk factors

Marshals multi-disciplinary support networks and in particular
recognise the crucial role of nurse practitioners in disease
management

Also...

Knowledge


Identifies patients with acute hepatitis B and can a rtain the
severity of their illness

Defines the different phases of chronic hepatitis B infection with a
clear understanding of serological results

Appreciates risks of transmission to close contacts
Has awareness of indications for therapy in both HBeAg positive and
negative hepatitis and the potential influence of genotype on choice of
therapy

Identifies patients where prophylaxis is required to prevent
reactivation and vertical transmission

Can determine an appropriate surveillance programme for those
patients with varices and/or hepatocellular carcinoma

Identifies patients who are appropriate candidates for liver transplant


Skills
Demonstrates ability to take a relevant history perform examination
and organise appropriate investigations

Able to advise risks of viral transmission
Interprets results of blood tests for hepatitis B antigen and antibody
Appreciates when liver biopsy is appropriate
Be able to select the most appropriate treatment and how to monitor
patient response

Able to select appropriate imaging techniques for evaluation of
abnormal results
Behaviours
Appreciates the cultural differences in the ethnic populations infected
and the influence this may have on screening


Provides advice and education to families and shows appreciation of
the potential difficulties that may arise

Understands the importance of cooperation with virologists and staff
in other clinical laboratories

Hepatitis B Vaccination

Postexposure ProphylaxisThis is indicated for all nonvaccinated individuals who are exposed to blood or infectious secretions.The first dose occurs < 12 hours of exposure.If known HBsAg +ve source, give 1 dose of HBIG.The other two doses of vaccine should be administered according to the usual schedule.PEP not needed if the patient is vaccinated and proven response.If no postvaccination testing, need a 2nd course of vaccination unless anti-HBs is detectable at the time of exposure.Documented non-responders need 2 doses HBIG given 1 month apart. Hepatitis B virus vaccination Not widely availableA combination vaccine (Twinrix®, GlaxoSmithKline), including Engerix-B and HAVRIX (hepatitis A vaccine) existsIs convenient and improves compliance for those who require vaccination against both hepatitis viruses Indications for vaccination:All neonates.All at high risk.Pregnant women (screen at first prenatal visit).Born in hyperendemic areas.Men who have sex with men.HIV infected patients.IVDU.Family and household contacts of HBV-infected persons.Healthcare workers.Patients on chronic haemodialysis.Patients with chronic liver disease. Prevaccination ScreeningScreen by anti-Hbc (prev infection) or HbsAg and anti-HBs (preferred).This is cost effective if the prevalence is >30%. EfficacyThe seroconversion rate is about 95 % in healthy adults.Efficacy decreases to 86 % in the fourth decade and 47 % in the sixth decade.The long duration of protection, despite low or undetectable anti-HBs levels, is probably due to the priming of memory cells, which are capable of eliciting anamnestic response when challenged. Postvaccination Testing:Only if at risk of recurrent exposure 1-2 months after course completion Neonates of HBsAg-positive mothers - do at age 9 to 15 months Adverse Reactions:Sore injection site in 25%Low grade fever, malaise, headache, joint pain and myalgia in 2%No teratogenic effects and can be administered during pregnancy 3 Main groups: Core S antigen ORF Pre1 ORF Pre 2 Polymerase gene Partial dsDNA Hep B virus genome organization PreCore 3. Plasma derivedHBsAg aloneExcel-lent efficacy and safety 2. Yeast derivedProduced by cloning HBV S gene in yeast cellsContain non-glycosylated HBV small S protein as the envelope antigen but no antigens of the pre-S regionsExamples: Engerix-B and Recom-bivax HB 1. Mammalian cell-derived recombinant vaccine: 3 typesa) S antigen+ antigen from the pre-S2 region b) and c) The other two contain antigens from both the pre-S1 and pre-S2 regionsExamples: Examples: Gen Hevac B, Bio-Hep-B/ Sci-B-Vac, AG-3 1st dose: Immediately2nd dose: 1 month after 1st dose3rd dose: 2 months after 2nd dose HepBsAg 1 month after 3rd injection Booster if titres inadequate If still inadequate, need two further vaccine injections If titres still inadequate then classified as non responder 1) Patients with underly-ing medical conditions eg. chronic kidney disease and immunosuppressed states: (response rate 50%)- vaccinate before haemodialysis 2) Genetically determined lack of response -Some lack response gene controlling anti-HBs production.- Individuals with celiac disease also appear to have a diminished response to HBV vaccination, possibly because of HLA haplotypes that predispose to both celiac disease and HBV vaccine nonresponse 3)Technical errors (eg. Intra-gluteal injection or inappropriate storage conditions) Management of Non-responders: Successful in about 60 % of patients Need i.m. injection (deltoid in adults/ vastus lateralis in infants If HBsAg +ve mother, give vaccine to neonate <12 h of birthSecond and third doses at 1-6m Written by Dr Sebastian Zeki Types of vaccines

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