1. 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

2. 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

3. 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

4. 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 1986. 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.

5. 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 1986. 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.

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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 15 12 10 9 10 6% 1% 14% 12% 0 13% 1% 50% 74% 85% 67% 68% -- 68% 52 148 805 118 53 675 474 2% 0 0.4% 0 1% 0

15. 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

16. Kane M et al. Lancet 2000; 355: 561-565 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 »...

17. 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

18. 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.

19. 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.

20. 1. Minor illness with temp <38.5 2. 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

21. 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