Public Health Response to Hepatitis B Exposure

A Case Study on Gaps and Opportunities to Improve Postexposure Care

In 2015, an estimated 257 million people were living with chronic hepatitis B virus (HBV) globally, with estimates in the United States as high as 2.2 million.^1–3 Only 25% of infected individuals in the United States are aware of their HBV infection, and less than 10% are able to access care and treatment.² If left untreated, chronic HBV infection can lead to serious liver complications, including liver cirrhosis and liver cancer, in up to 25% of infected individuals.^4,5 Hepatitis B can be transmitted through direct contact with infected blood, unprotected sex with an infected individual, use of illicit drugs, contaminated or unsterile injecting equipment, and most commonly worldwide from an infected mother to her newborn during childbirth (or during pregnancy in women with high viral load).⁵ Likely attributed to the recent opioid epidemic, Centers for Disease Control and Prevention (CDC) has reported an increase in cases of acute HBV infections in 3 states among non-Hispanic whites aged 30 to 39 years who reported injection drug usage.⁶ The opioid epidemic increases the risk of potential exposure to hepatitis B, and our public health system must be ready to provide timely postexposure prophylaxis (PEP).

Hepatitis B vaccination is highly effective at preventing HBV infection and is recommended in the United States for all infants at birth and adults considered to be high risk for hepatitis B (including persons who inject drugs, persons infected with human immunodeficiency virus, men who have sex with men, healthcare personnel, and persons with diabetes).^7,8 The hepatitis B vaccine is generally a 3-dose series administered on a 0, 1, and 6-month schedule.⁸

Centers for Disease Control and Prevention has published PEP guidelines for both occupational and nonoccupational exposure to HBV. The guidelines, which are intended to increase immune response and prevent HBV infection after exposure, may consist of hepatitis B immune globulin (HBIG) and HBV vaccine, depending on the exposed person's vaccination status and source of exposure.^8,9 These guidelines state that after nonoccupational exposure to an HBV infected person, (1) persons who have written documentation of a complete hepatitis B vaccine series and who did not receive postvaccination testing should receive a single vaccine booster dose, (2) persons who are in the process of being vaccinated but who have not completed the vaccine series should receive the appropriate dose of HBIG and should complete the vaccine series, and (3) unvaccinated persons should receive both HBIG and hepatitis B vaccine as soon as possible after exposure (preferably within 24 hours), and the hepatitis B vaccine series should be completed in accordance with the age-appropriate vaccine dose and schedule.^8,9

CASE PRESENTATION

A 55-year-old Caucasian female was exposed to HBV through unprotected sexual contact on October 1, 2017 (Fig. 1). The woman's partner had used intravenous drugs in the past and was chronically HBV infected. The woman had received 2 doses of the hepatitis B vaccine, with the first dose in June 2017 and the second dose in August 2017. Her third dose was scheduled for December 2017.

FIGURE 1: Displays the timeline of events surrounding a case of exposure to HBV.

The woman went to her local health department within 24 hours of the exposure, but the recommended adult HBIG dosage (5 mL) was unavailable. She then called the Hepatitis B Foundation consultation phone line. The Hepatitis B Foundation assisted by contacting hospitals near the woman's residence to find the appropriate postexposure HBIG dose. The first hospital contacted was “uncomfortable” with the administration of HBIG and felt it was the responsibility of the local health department. The second hospital contacted carried the correct HBIG dose, but when the patient arrived, the hospital emergency department refused to administer it, asserting that HBIG administration was not done in the emergency setting and “it never has been done in this hospital.” The Hepatitis B Foundation contacted the state viral hepatitis program for assistance with providing the woman with the care she needed. Unfortunately, the state viral hepatitis program representative was uncomfortable with being asked to advocate for the patient with the hospital, primarily because “CDC's guidelines are a bit confusing and can seem to contradict themselves at times.” The woman ultimately did not receive HBIG.

Three days later, the woman received a PEP dose of HBV vaccine at her local health department because the hospital refused to administer it. The woman also plans to complete the series as scheduled in December 2017, receiving a total of 4 doses of hepatitis B vaccine. Although the woman did receive a dose of PEP hepatitis B vaccine, she was unable to receive the adequate HBIG.

DISCUSSION

The CDC PEP guidelines for nonoccupational exposure explicitly state: “persons who are in the process of being vaccinated but who have not completed the vaccine series should receive the appropriate dose of HBIG and should complete the vaccine series, preferably within 24 hours.”^8,9 However, the HBIG dose can still be effective in preventing infection if given within 14 days of exposure but is unlikely to have any effect after 14 days. This patient did not receive any HBIG and is at risk for developing HBV infection because of the confusion around administration. It is concerning that an incompletely vaccinated individual was unable to access HBIG after an exposure to HBV, even after seeking out HBIG and involving the Hepatitis B Foundation, 2 hospitals, and viral hepatitis program staff in her state. Although the CDC guidelines are straightforward, this event demonstrates a lack of knowledge of the CDC PEP guidelines and understanding of who is responsible for providing this very important service to patients. With the rise of the opioid epidemic and the increasing number of cases of acute HBV infections in the United States, clinical providers in emergency department settings should be prepared to administer HBV PEP and recognize this as their responsibility. In addition, providers should know how to report both exposures and hepatitis B infections to local and state health departments to assist in case management and prevention of additional cases.¹⁰ All health departments and viral hepatitis program staff should have a clear understanding of the CDC HBV PEP guidelines, so that they can help individuals who need assistance finding HBIG at a site near them and advocate for patients who are unable to obtain PEP services in healthcare facilities.