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Flexibility will be the guiding principle in upcoming recommendations on health care workers who were vaccinated against hepatitis B as infants.
Instead of directing hospitals to test all young health care workers for antibodies to hepatitis B surface antigen, the Centers for Disease Control and Prevention will present two approaches, medical epidemiologist Sara Schillie, MD, MPH, MBA, told the Advisory Committee on Immunization Practices (ACIP).
“There’s not a right or a wrong approach,” she told our sister publication, Hospital Employee Health.
Universal HBV vaccination of infants is a public health success – and a new challenge for health care employers. Health care workers who were vaccinated against hepatitis B as infants were never tested for an antibody response.
CDC currently recommends a three-dose series of HBV vaccine for health care workers. More than 90% of health care workers respond to the full series. Many non-responders show an immune response to an additional one to three vaccinations, but a small portion (about 5%) of health care workers will remain non-responders. If non-responders have a bloodborne pathogen exposure and the source patient is positive for hepatitis B surface antigen, the exposed health care worker should receive hepatitis B immune globulin and additional vaccination, the CDC recommends.
For new hires who were vaccinated as infants, employers can take a pre-exposure or post-exposure approach, according to proposed recommendations discussed by ACIP.
In the pre-exposure approach, trainees or newly hired workers who were vaccinated as infants would be tested for HBV antibodies. If they have a level of at least 10 mIU/ml, they are considered protected and do not need further vaccination or testing. Those with lower levels of HBV surface antibodies would receive a single dose, and be re-tested, and if necessary receive two more doses.
As with current guidelines, health care workers who failed to respond sufficiently to the vaccine would be considered non-responders.
A post-exposure approach would involve testing the health care worker for antibodies at the same time that the source patient is tested for hepatitis B surface antigen. Health care workers with a low level of antibodies would receive the hepatitis B vaccine as well as HBV immune globulin.
There are a number of issues to consider, notes Schillie:
* Trainees have a higher risk of bloodborne pathogen exposure than other health care workers. About 54% of needlesticks are unreported. So it would make sense to test trainees upon hire, says Schillie.
* Some facilities, such as long-term care centers, have a high turnover of staff. Testing those employees may be logistically challenging and expensive, she says. “It might be more practical for them to use a post-exposure approach,” she says.
* HBV vaccination of infants will eventually reduce the population of source patients who are hepatitis B surface antigen positive. The prevalence of hepatitis B in the community and among source patients may influence the decision to do routine, pre-exposure testing versus post-exposure testing.
Currently, 72% of health care conduct pre-exposure testing of health care workers who were vaccinated as infants, and 20% take a post-exposure approach. About 7% give employees a challenge dose of vaccine and then test for antibodies.