Resource Packages: Hepatitis B

Historical Overview

Hepatitis B was first recognised less than 100 years ago, when the German researcher Lurman observed that 15% of 1,289 shipyard workers developed jaundice several weeks to six months after receiving a smallpox vaccine prepared from human lymph.

Not until the late 1930’s, however, was the link between hepatitis and blood transmission firmly established in England, when the disease broke out among people inoculated with yellow fever vaccine that was stabilised by the addition of human serum. In the early and mid 1940’s, researchers in both the USA and England documented the occurrence of hepatitis following direct transfusion of blood or plasma, a practice that became widespread during World War Two.

In the late 1960’s and early 1970’s, a virus designated as the “Dane particle“ was found to be the cause of hepatitis B. The virus has a core and an outer shell and produces a large excess of surface antigen, known as hepatitis B surface antigen (HBsAg). This antigen was referred to as Australian Antigen because it was originally isolated from the blood of an Australian Aboriginal.

Once transmitted, the virus usually has a long incubation period, lasting two to six months, before signs of illness appear.

Hepatitis B has also been known as: Serum hepatitis, Viral hepatitis B and Homologous serum jaundice.

Recent Developments

Hepatitis B virus (HBV) is a worldwide pandemic disease. Hepatitis B infection is more common in certain high-risk groups. These groups include:

People who inject drugs
People who have more than one sexual partner
People from ethnic groups which contain a large number of hepatitis B carriers
Health care workers such as nurses, doctors, and dentists

Hepatitis B can be transmitted in blood, blood products and sexual fluids. Infection may be transmitted between household contacts and between sexual partners (heterosexual and homosexual). Communally used razors and toothbrushes have been implicated in hepatitis B transmission.

Faecal - oral route transmission has not been demonstrated.

Incubation period averages 60 to 90 days (can be 45 to 180 days). The period of communicability extends from several weeks before antibody tests or symptoms indicate infection until the patient is hepatitis B antigen negative and hepatitis B surface antibody positive.

Most patients infected with HBV recover completely and develop lifelong immunity against reinfection, but some become chronically infected carriers.

Infection during infancy and early childhood, while usually asymptomatic, carries a very high risk of progression to the chronic carrier state. Adult infection may be either symptomatic or asymptomatic, and most adults recover fully. Only 5 to 10% develop chronic carrier state.

Standard precautions must be practiced at all times. A single room is not routinely required for acute hepatitis B patients although the patient who is bleeding is best managed in a single room.

Notification to the Public Health Unit: Laboratories notify hepatitis B positive tests to the Public Health Unit. Doctors who diagnose acute hepatitis B should notify the Public Health Unit to facilitate risk factor data collection.

Prophylaxis: All health care workers (HCW) whose work involves participation in tasks or activities with the potential of exposure or contact with blood or other body substances are to be offered, free of charge, a course of hepatitis B vaccine. This should occur within 10 working days of commencing employment at the health care establishment.

Immunisation: Adult immunisation schedule consists of three 1.0 ml doses given at 0, 1 and 6 months. The vaccine should be administered by intramuscular (IM) injection. The deltoid muscle is the preferred site in adults. health care workers should be encouraged to seek post immunisation testing, so that non-responders can be alerted to the need for extra booster or hepatitis B immunoglobulin (HBIG) if exposed to infected blood.

health care workers should be tested for hepatitis B surface antibodies (anti-Hbs) 2 to 4 months after the third dose of vaccine. Immunity should not be assumed unless satisfactory levels of anti-Hbs have been verified.

Staff are recommended to maintain their immunity with booster doses at five-year intervals. The booster is a single dose of hepatitis B vaccine given intramuscularly in the deltoid muscle.

Immunisation against hepatitis B must not lead to a lowering of infection control practices.

The Hepatitis Advisory Committee has recommended that the health care worker’s role in prevention of hepatitis B be included in this resource package.

The most important initiatives in preventing the spread of hepatitis B in the Australian community are:

The neonatal hepatitis B immunisation program. It is especially important that the infants of carrier mothers receive both immunoglobulin and vaccine to prevent infants becoming chronic carriers since this is associated with a very high risk of serious liver disease in early adult life. Infants of carrier mothers and infants born into population groups with a rate of chronic hepatitis B carriage more than 2% are eligible for free vaccine under this program
Standard precautions used by health care workers
Vaccination of health care workers
The needle and syringe program. This helps reduce the spread of hepatitis B, Human Immunodeficiency Virus (HIV) and hepatitis C in injecting drug users. This in turn minimises the pool of infection and therefore goes a long way in protecting the rest of the community from infection
Infection control procedures used by members of occupational groups who pierce skin in non-medical settings such as body piercers and tattooists

References

Benenson A S ed, 16th edition, 1995, Control of Communicable Diseases in Man, American Public Health Association, Washington.

Bennett J V, Brachman P S.and Sandford J P, eds, 1992 3rd edition, Hospital Infections, Little, Brown and Company, Boston.

Manly Hospital and Community Health Services, 1992, Infection Control Manual, Manly.

NSW Health Department, 1996, Hepatitis B and Health Care Workers 96/40, Aids/Infectious Diseases Branch, Sydney.

Reid D, Grist N R, Pinkerton I W, 1986, Infections in Current Medical Practice. Butterworths, London.

The Australian Immunisation Handbook, 6th edition,1997, National Health and Medical Research Council, Commonwealth of Australia.

The Sutherland Hospital, Caringbah, 1993, Infection Control Manual. Sutherland.

Viral Hepatitis Prevention Board,1994, Hepatitis B as an Occupational Hazard. Villadsen and Christensen, USA.

Albion Street Centre
150 - 154 Albion Street Surry Hills NSW 2010 Australia
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