• All men reporting same sex sexual contact (MSM)
• Men and women with a history of injecting drug use
• Victims of sexual assault
• Male and Female sex industry workers
• HIV positive patients (and patients with Hepatitis B or C infection) * follow vaccination protocol for HIV positive patients.
• Ongoing sexual contact with a partner from high to moderate prevalence areas-not required if partner is known to be Hepatitis B surface antigen negative. (Everywhere except UK, USA, Western Europe and Australia are high to moderate prevalence areas.)
• Blood transfusion/ invasive medical procedures in the same areas-test for Hepatitis B but vaccination is not required if there is no ongoing risk.
• Tattoos or piercings performed in unlicensed settings (low risk except in prison) – test for Hepatitis B but vaccination is not required except if
  deemed an ongoing/ future risk.
• Sexual contacts of any of the above groups.
• BBV screening and vaccination for occupational reasons should be done via the individual’s occupational health department so that the patient’s immune status can be appropriately documented.

What tests to use:

Request Hepatitis B screen on virology form - the lab will test for Hep B core antibody (c Ab). The lab will perform other appropriate tests automatically if these tests are positive

If the patient is unclear on whether vaccinated or tested and there is no record available, it is acceptable to check for BOTH exposure and vaccine induced immunity (HepB cAb and HepB sAb)

• See History and Clinical Examination for how to request tests on NaSH
• Do not request a test for Hepatitis A IgG on HIV negative patients.

TWINRIX: Use Hepatitis A and B vaccine for all MSM and PWID unless they have previously completed a vaccination course against Hepatitis A for travel-2 doses 6 months apart- or have had documented Hepatitis A infection. Patients who are HCV carriers or HIV positive should also receive Twinrix vaccination and their GP should be informed. (For HIV positive individuals, please follow specific protocol.)

ENGERIX B: Use in all other groups.

(Patients who are known Hep B, should be offered Hep A vaccination alone and their GP should be informed.)

Vaccine Course: 3 or 4 doses depending on schedule used

Twinrix and Engerix: Use the standard vaccination course routinely (Doses at 0,1 and 6 months)

Use an accelerated course (Doses at 0, 1, 2 and 12 months) for post exposure prophylaxis.

Use the super-accelerated course (Doses at 0, 1, 3 and 52 weeks) only in
exceptional circumstances (eg current partner with highly infectious hepatitis B infection and consider Hepatitis B Immunoglobulin-see below)

Young people aged 11-15- This group can be given adult strength Engerix B (we do not stock paediatric strength Engerix B). They require only 2 doses at 0 and 6 months.

Do not give booster doses to immunocompetent patients. We no longer give boosters or check Hepatitis B antibody levels routinely in patients with normal immune status who have completed a Hepatitis B vaccination course. This is because the vast majority of individuals will have some response to vaccination and because protection will last for 30 years or more following vaccination. (Health care workers are still offered a booster dose at 5 years after their primary vaccination course but this should be done by occupational health to allow for documentation).

However a booster should be given to anyone who has a significant exposure (e.g. contact with Hep B surface antigen positive individual) even if they have had a complete course of vaccination.
Hepatitis B surface Antibody levels can be checked in those at particular risk of infection (eg partners of confirmed HepB carriers) or in whom infection has particular implications (eg those coinfected with HIV or Hepatitis B or C, or those commencing PrEP)

When to Start vaccination

Start at first visit while awaiting results. The standard vaccination schedule (0,1 and 6 months) should be followed routinely.

For high-risk patients the accelerated schedules will give earlier antibody protection and have a higher uptake.

The accelerated course (0, 1, 2, 12 months) should be used for PEP in those where the hepatitis B status of the source is unknown and for those at high risk of immediate exposure.

This group includes:

• PEP for needlestick injuries from discarded needles
• PEP following sexual assault after risk assessment.

Give patient a hepatitis vaccination record card showing that the first vaccination has been given and suggested approximate intervals for further vaccination. Only allow patients to make an appointment for the next vaccination due and NOT the whole course. They can be offered the option of repeat doses at their GP and can present the card as a record and prompt for the next dose. If directing patients to the GP you MUST send GP the standard letter on Hepatitis Vaccination. We will not routinely recall patients for vaccination.

The super accelerated course (0,1, 3 and 52 weeks should be reserved for exceptional cases at very high risk (eg exposure to a partner with suspected acute hepatitis B/known hepatitis B carrier). He individual should

Individuals who have a sexual partner who is known to have highly infectious hepatitis B (Hepatitis B surface antigen and e antigen positive) should be offered protection with vaccine, and if seen within one week of the last sexual contact should also be offered Hepatitis B Immunoglobulin-(HBIG).  HBIG ideally should be given within 24 hours of exposure but can be given up to 7 days post exposure. This is available from Borders General Hospital pharmacy.

Sexual contacts of an individual with newly diagnosed chronic hepatitis B should be offered vaccine; HBIG may be considered if unprotected sexual contact with the new partner first occurred in the past week.

Individuals should be advised on the appropriate use of condoms, at least until after the second dose, and on the importance of completing the course to minimise the risk of infection.

Sexual contacts should have their surface antibody levels checked one to two months after the completion of a primary course of vaccine. An antibody level of >100IU/L is regarded as satisfactory. If the level is between 10 and 100 IU/L a further dose of vaccine should be given. For many of these individuals the surface antibody check and re-immunisation if required could take place at their GP rather than at Borders Sexual Health. Communication to the GP would be required. Please check and update permissions on NASH.