A 23 year old business woman got two shots of hepatitis B 1 month apart 2 years ago. Today she is at your practice for ending the schedule. What should be done? u A. start again from zero. u B. you offer a third dose of hepatitis B vaccine u C. you first control the anti-HBs and if > 10 IU/L, u D. you tell her she is protected

A 23 year old business woman got two shots of hepatitis B 1 month apart 2 years ago. Today she is at your practice for ending the schedule. What should be done? u A. start again from zero. u B. you offer a third dose of hepatitis B vaccine u C. you first check the anti-HBs and if > 10 IU/L, u D. you tell her she is protected

Delayed and Incorrect Doses of Hepatitis B Vaccine  If vaccination series is interrupted – no need to restart series – second dose missed: give missing dose and continue series – third dose missed: complete series  If an incorrect (i.e., low) dose of vaccine is given, dose should be repeated

A 45 year old nurse is going to work in an orphanage in an Eastern European country. She received 3 doses of hepatitis B vaccine in She can remember she was tested and her anti-HBs was 1124 mIU/ml. What do you recommend? u A. tell her she is protected for life. u B. tell her she should start vaccination from zero again u C. offer her one additional dose and measure the anti- HBs one month later again. u D. test for anti-HBs before any further intervention.

A 45 year old nurse is going to work in an orphanage in an Eastern European country. She received 3 doses of hepatitis B vaccine in She can remember she was tested and her anti-HBs was 1124 mIU/ml. What do you recommend? u A. tell her she is protected for life. u B. tell her she should start vaccination from zero again u C. offer her one additional dose and measure the anti- HBs one month later again. u D. test for anti-HBs before any further intervention.

As part of your adolescent immunization programme you are considering post-vaccination serologic testing. Is this indicated? u A. yes, for all ado ’s u B. no, for no one. u C. yes, for some adolescents.

As part of your adolescent immunization programme you are considering post-vaccination serologic testing. Is this indicated? u A. yes, for all ado ’s u B. no, for no one. u C. yes, for some adolescents.

Post-Vaccination Testing Vaccine highly immunogenic >95% seroconversion after 3-dose series Almost all vaccinated persons protected Post-vaccination testing NOT indicated after routine immunization

A 33 year old HCW comes in your practice for anti-HBs control 8 years after he got a complete vaccination schedule. And he wants to be tested. What shall you do? u A. he is protected for life u B. he should start vaccination from zero again u C. offer him one additional dose and measure the anti-HBs one month later again. u D. try to check whether anti-HBs data are available from the past u E. tell him he is not protected u F. check his anti-HBS as requested

A 33 year old HCW comes in your practice for anti-HBs control 8 years after he got a complete vaccination schedule. And he wants to be tested. What shall you do? u A. he is protected for life u B. he should start vaccination from zero again u C. offer him one additional dose and measure the anti-HBs one month later again. u D. try to check whether anti-HBs data are available from the past u E. tell him he is not protected u F. check his anti-HBS as requested

Long-Term Protection with Hepatitis B Vaccine  Vaccine provides long-term protection  Immunity persists despite loss of anti-HBs  documented protection up to 15 years – lifelong protection likely – continued follow-up needed to determine duration of protection Booster doses of hepatitis B vaccine NOT currently recommended

Mechanism of Long-Term Protection with Hepatitis B Vaccine Primary vaccination series Immune memory Anamnestic antibody response Rapid rise in anti-HBs Protection from infection Exposure to HBV

Serologic Response to Booster Dose of Hepatitis B Vaccine Primary series Booster dose (simulating natural infection) Source: Williams, CDC 2 weeks post-booster 4 weeks post-booster 1 year post-booster

Long-Term Protection with Hepatitis B Vaccine Among Vaccinated Infants and Children Country Anti-HBc Positive HBsAg Positive Anti-HBs >10 mIU/mln Years f/u China Hong Kong Taiwan Italy Gambia Italy % 1% 14% 12% 0 13% 1% 50% 74% 85% 67% 68% -- 68% % 0 0.4% 0 1% 0

Long-lasting protection: implications u scientific data do not support the need for routine booster vaccinations (ACIP, ACIP Canada, VHPB) u therefore, no booster recommendation : –for universal HB vaccination programmes (infants, children and adolescents) –for adults who are immunocompetent

Kane M et al. Lancet 2000; 355: Long-lasting protection: implications u European consensus group on hepatitis B immunity (October 1998, Florence): u no need for booster doses in immunocompetent individuals u HB booster vaccination to be considered for mmunocompromised individuals: »haemodialysis »chronic renal failure/liver disease »HIV positive »...

Long-lasting protection: benefits u Maintains immunity in the population u Reduces morbidity and mortality u Reduces transmission in the population u Protects against disease for longer  Reduces direct and indirect costs of booster vaccination programs

A mother brings her child for a second hepatitis B shot, and the child has a cold and fever of 38.0°C. What should you do? u A. give the shot as scheduled u B. send the child home, and tell the mother to bring the child back over one week. u C. give to shot and keep the child in your clinic for 24h. Observation.

A mother brings her child for a second hepatitis B shot, and the child has a cold and fever of 38.0°C. What should you do? u A. give the shot as scheduled u B. send the child home, and tell the mother to bring the child back over one week. u C. give to shot and keep the child in your clinic for 24h. Observation.

1. Minor illness with temp < Allergy or asthma 3. History of seizures 4. Family history of seizures 5. Treatment with antibiotics 6. Infection with HIV The Following are NOT Contraindications to Vaccination

7. Chronic diseases - such as chronic heart, lung, liver, kidney diseases 8. Stable neurologic conditions - such as cerebral palsey, Down’s syndrome 9. Premature infants 10. Jaundice at birth 11. Breast feeding 12. Pregnancy The Following are NOT Contraindications to Vaccination