to the primary case (within 8 weeks of exposure to the
primary case where there is more than 1 contact in the
household).A booster dose of hepatitis A vaccine is usually given 6 –
12 months after the initial dose. A second booster dose can
be given 20 years after the previous booster dose to those
who continue to be at risk. Specialist advice should be sought
on re-immunisation of immunocompromised individuals.
In children under 16 years, a single dose of the combined
vaccineAmbirix®can be used to provide rapid protection
against hepatitis A. Public Health England recommends the
use of intramuscular normal immunoglobulin p. 773 in
addition to hepatitis A vaccine for prevention of infection in
close contacts (of confirmed cases of hepatitis A) who have
chronic liver disease or HIV infection, or who are
immunosuppressed. For further guidance, see
Immunoglobulins p. 770.
Post-exposure prophylaxis is not required for healthy
children under 1 year of age, so long as all those involved in
nappy changing are vaccinated against hepatitis A. However,
children 2 – 12 months of age can be given a dose of hepatitis
A vaccine if it is not possible to vaccinate their carers, or if
the child becomes a source of infection to others [unlicensed
use]; in these cases, if the child goes on to require long-term
protection against hepatitis A after thefirst birthday, the full
course of 2 doses should be given.
Hepatitis B vaccine
Hepatitis B vaccine p. 796 contains inactivated hepatitis B
virus surface antigen (HBsAg) adsorbed onto an adjuvant. It
is made biosynthetically using recombinant DNA
technology.
From August 2017 , vaccination against hepatitis B is
recommended as part of theroutine immunisation
schedule. Primary immunisation (seeRoutine immunisation
schedule) requires 3 doses, given at intervals of 1 month from
the age of 2 months, to be given as part of the combined
diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis
and haemophilus influenzae type b vaccine p.^790 (Infanrix
hexa®).
As part of theselective neonatal immunisation
programme, vaccination is recommended for neonates
whose mothers have had acute hepatitis B during pregnancy
orare positive for hepatitis B surface antigen (regardless of
e-antigen markers). Hepatitis B vaccination is started
immediately after birth with a dose of the monovalent
hepatitis B vaccine (no later than 24 hours after delivery),
followed by a second dose at 4 weeks; the routine
immunisation combination vaccine (Infanrix hexa®) at weeks
8 , 12 and 16 ; and a further dose of the monovalent hepatitis
B vaccine at one year of age.
Neonates born to highly infectious mothers should also
receive hepatitis B immunoglobulin p. 773 at the same time
as thefirst dose of monovalent hepatitis B vaccine, but
administered at a different site—more detailed guidance is
given in the handbookImmunisation against Infectious
Diseasewww.gov.uk/government/publications/hepatitis-b-the-
green-book-chapter- 18.
Followingsignificant exposure to hepatitis B(e.g.
through needle-stick injury or unprotected sex) and forpre-
exposure prophylaxis in high-risk groups,’an accelerated
schedule’using the single, monovalent hepatitis B vaccine is
recommended immediately, with the second dose given
1 month after the initial dose, and the third dose given
2 months after the initial dose. For those at continued high
risk following exposure, a fourth dose should be given
12 months after thefirst dose. More detailed guidance is
given in the handbookImmunisation against Infectious
Disease.
Specific hepatitis B immunoglobulin can also be indicated
for use with the vaccine in those accidentally inoculated and
in neonates at special risk of infection. If hepatitis B
immunoglobulin is indicated, it should be given as soon as
possible, ideally at the same time or within 24 hours of the
first dose of vaccine, but not after seven days have elapsed
since exposure. See alsohepatitis B immunoglobulinin
Immunoglobulins p. 770.
In the UK, groups at high-risk of hepatitis B include:
.parenteral drug misusers, their sexual partners, and
household contacts; other drug misusers who are likely to
‘progress’to injecting;
.adolescents who are at risk from their sexual behaviour;
.close family contacts of an individual with chronic
hepatitis B infection;
.children with haemophilia, those receiving regular blood
transfusions or blood products, and carers responsible for
the administration of such products;
.children with chronic renal failure including those on
haemodialysis. Children receiving haemodialysis should be
monitored for antibodies annually and re-immunised if
necessary. Home carers (of dialysis patients) should be
vaccinated;
.children with chronic liver disease
.patients of day-care or residential accommodation for
those with severe learning difficulties;
.children in custodial institutions;
.children travelling to areas of high or intermediate
prevalence who are at increased risk or who plan to remain
there for lengthy periods;
.families adopting children from countries with a high or
intermediate prevalence of hepatitis B;
.foster carers and their families.
Following a primary course of immunisation, most children
do not require a reinforcing dose of a hepatitis B-containing
vaccine. A single booster dose should be offered to
healthcare workers aroundfive years after primary
immunisation, to patients on renal dialysis with anti-HBs
levels below 10 mlU/mL, and at the time of a subsequent
significant exposure.
Immunisation does not eliminate the need for
commonsense precautions for avoiding the risk of infection
from known carriers by the routes of infection which have
been clearly established, consultGuidance for Clinical Health
Care Workers: Protection against Infection with Blood-borne
Viruses(available atwww.dh.gov.uk). Accidental inoculation
of hepatitis B virus-infected blood into a wound, incision,
needle-prick, or abrasion may lead to infection, whereas it is
unlikely that indirect exposure to a carrier will do so.
A combined hepatitis A and B vaccine p. 794 is also
available.Human papillomavirus vaccine
Human papillomavirus vaccine is available as a bivalent
vaccine (Cervarix®) or a quadrivalent vaccine (Gardasil®).
Since 2012 , onlyGardasil®is offered as part of the national
immunisation programme.Cervarix®is licensed for use in
females for the prevention of cervical cancer and other pre-
cancerous lesions caused by human papillomavirus types 16
and 18 .Gardasil®is licensed for use in females for the
prevention of cervical and anal cancers, genital warts and
pre-cancerous genital (cervical, vulvar, and vaginal) and anal
lesions caused by human papillomavirus types 6 , 11 , 16 , and
18. The vaccines may also provide limited protection against
disease caused by other types of human papillomavirus. The
two vaccines are not interchangeable and one vaccine
product should be used for an entire course.
Human papillomavirus vaccine will be most effective if
given before sexual activity starts. From September 2014 ,a
2 -dose schedule is recommended, as long as thefirst dose is
received before the age of 15 years. Thefirst dose is given to
females aged 11 to 14 years, and the second dose is given
6 - 24 months after thefirst dose (for the purposes of
planning the national immunisation programme, it is
appropriate to give the second dose 12 months after theBNFC 2018 – 2019 Vaccination 781
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