1. MODERATOR : DR. ABHISHEK RAUT
HEPATITIS B
EPIDEMIOLOGY AND WHO POSITION ON VACCINE
VIKASH KESHRI
MODERATOR : DR. ABHISHEK RAUT

2. INTRODUCTION
PROBLEM STATEMENT
EPIDEMIOLOGY
PREVENTION AND CONTROL
HEPATITIS B VACCINE
WHO POSITION ON HEPATITIS B VACCINE

3. INTRODUTION
Hepatitis b initially called as serum hepatits is an acute systemic illness with major pathology in liver.
Besides 2 billion infected cases world wide approximately 36 millions live with chronic infection.
These chronically infected people are at increased risk of death from cirrhosis of liver or hepatocellular carcinoma.

4. PROBLEM STATEMENT Hepatitis B is endemic in almost all part of world
60% of world population live in endemic area
Estimated 2 billion people infected
360 million live with chronic infection
600,000 person dies annually as result of consequence of hepatitis B every year
Estimated 25% child dies in later life as a consequence of hepatitis B infection.
Vaccine coverage estimated is 69%

7. Problem statement cont…..
SEAR:
Estimated one third population in the region infected
80 million carrier
Estimated 200,000 death occur annually
vaccine coverage 41% according to WHO-UNICEF antigen study
INDIA:
fall in intermediate endemicity group
HBsAg prevalence between 2% to 7%.
Estimated million cases per year.
40 million carriers.
100,000 death annually by disease related to HBV infection.
Of 25 million newborn annually, 1 milion runs lifetime risk of HBV infection

8. EPIDEMIOLOGY AGENT FACTOR: Agent :
Hepatitis B virus belongs to hepadenavirdae family.
Complex 42 nm. Double stranded enveloped DNA virus.
Also known as “Dane” particle.
Has affinity for liver and hepatocytes

9. Reservoir of infection
Human being only reservoir
Infection spread by cases and carrier
Carrier defined as persistence of HBsAg > 6 months
Resistance of virus:
quite stable , can survive for days in environmental condition.
Can be destroyed by sodium hypochlorite
Also by autoclaving for 30 to 60 minutes.
Period of communicability:
from incubation period upto disappearnce of HBsAg and upto appearance of antibody.
But can be years.

10. HOST FACTOR outcome age independent
For acute Hepatitis B occurs in 1% perinatal, 10% early childhood (1-5 yrs.) and 30% in older children (>5 yrs. Age)
Development of Chronic hepatitis is inversely proportional to age

11. HIGH RISK GROUPS Health care workers High risk sexual behavior
Commercial sex worker
Frequent blood transfusion reciepient
Injectable drug users
Immunocompromised individuals
Infant of HBV carrier

12. Routes of transmission:
Modes of transmission
Infective materials:
Blood and blood products, serous exudates, saliva, seminal and vaginal fluids, etc.
Routes of transmission:
1. Percutaneous 2. sexual 3. perinatal
4. Others routes

13. Percutaneous routes injectable drug users
Nonsexual contacts between individuals
Contact with intimate objects
Contact of open skin or mucous membrane with infected materials.
Occupational exposure: needlestick injury, surgical procedure, handling infected materials.
Rituals: circumcision, tatooing, nose and ear piercing.

14. Sexual routes perinatal route: Sexual contact with infected person
Favourable factors:
-Contact with a person during active infection
- H/O sexually transmitted disease
- promiscuosity
- Male homosexuals
perinatal route:
important contributor of high prevalence of infection
Mostly around perinatal period.

15. Other routes: Acute infection during third trimester increases risk.
In utero transmission very rare
No evidence of transmission via breast feeding
Other routes:
Interpersonal contact specially childhood. May be because of skin to skin contact.
INCUBATION PERIOD:
Varies from 30 to 180 days
Average 75 days
HBsAg can be detected as early as 30 days and may persist for several months to years.

16. Clinical features Insidious onset
Early symptom : malaise, weakness , anorexia
Ranges from mild asymptomatic infection to fulminant hepatitis to hepatocellular carcinoma to death.

17. Subclinical infection Acute hepatitis B infection
EXPOSURE
Clinical infection
-jaundice
-flu like symptom
Asymptomatic Or
Subclinical infection
Acute hepatitis B infection
Recovery Or
Immunity
Fulminant hepatitis
Chronic
Carrier
Minimal liver
Disease
Chronic Hepatitis
Death
Primary hepatocellular carcinoma
cirrhosis
DEATH

18. PREVENTION AND CONTROL
GOALS OF PREVENTION:
to decrease prevalence of chronic carrier and chronic liver disease
prevention of acute hepatitis B infection
Strategies:
Hepatitis B vaccination.
Screening of blood, plasma, organ and semen donor.
Universal precautions.

19. HEPATITIS B VACCINATION
Active immunization
Passive immunization
ACTIVE IMMUNIZATION
Two types of vaccine available
1. Plasma derived vaccine
2. Recombinant DNA vaccine
PLASMA DERIVED VACCINE:
Based on HBsAg derived from plasma of human carrier.
Formalin inactivated
Intramuscularly administered
Dose = 1 ml. (contains > 20 mcg. HBsAg.)
costlier

20. Recombinant DNA vaccine
Introduced in in USA.
Has replaced plasma derived vaccine.
Cost effective and equally effective
Available as monovalent or combined vaccine
Active substance:
-HBsAg derived from culture of yeast or mammalian cells
Adjuvant:
- Alum or thiomersal
Storage:
-2 to 8°c
- freezing avoided
-vaccine survive for 7 day at 45°C and for 1 month at 37°c

21. Administration Age : No. Of doses: no need of booster dose.
Ideal first dose at birth ( within 24 hours)
Next 2 or 3 dose according to immunization schedule
Can be given at any age
No. Of doses:
3 or 4
First at birth , second and third with DPT1 and DPT3.
First at birth, second, third and fourth with DPT and OPV routine
Older child and adults 3 doses at day o, 1 month, 2 month
no need of booster dose.

22. Hepatitis B vaccine in immunocompromised state:
Dose :
- 0.5 ml. for child < 10 years
- 1 ml. For adults
Route :
- intramuscularly
Site :
- left upper arm for adults
- anterolateral thigh for young infants
Hepatitis B vaccine in immunocompromised state:
- not contraindicated but special attention required

23. Immunogenicity and Duration of protection
Usually life long immunity
Hepatitis B or even chronic carrier stage rarely occur.
Role of natural booster by sub- clinical infection is yet to be proved
Adverse reaction:
infrequent and rare
Myalgia , transient fever , local pain
No serious adverse effect
Very rarely anaphylactic reaction
No relation with G.B. syndrome or multiple myeloma
GACVS recommends excellent safety profile

24. Contraindications: H/O allergic reaction to component of vaccine.
Pregnancy and lactation no contraindication.
HIV positive individual and premature babies can be given vaccine
CATCH UP STRATEGY:
Vaccinate older children and adults in low and intermediate endemicity area for population immunity
Target age specific cohort and high risk individual
Strategy may be mandatory vaccination at school and college entry and before joining job.
Target strategic point i.e. STD clinics, centre for IDUs.
Continuous surveillance.

25. PASSIVE IMMUNIZATION
Hepatitis B immunoglobulin used for temporary post-exposure prophylaxis.
Combined active and passive vaccination better in following cases:
- Newborn of HBsAg +ve mother specially if baby +ve
- Percutaneous exposure
-Sexual exposure
- After liver transplant in case of recurrent HBV infection
Time :
within 6 hours of exposure and maximum upto 48 hours.
Dose: to ml. / kg. body weight.
Provides short term passive immunity for 3 months.

26. WHO POSITION
All newborn should receive birth dose of hepatitis B within 24 hours of birth, in all countries irrespective of their immunity status.
Immunization programme must include HBV.
Proper Reporting and monitoring
MCH care needs to be strenghthened
Schedule include :
- First birth dose within 24 hours of birth , followed by either
-2 dose schedule with 2 nd and 3rd dose with -DPT 1 and DPT3
-Or 3 dose schedule with routine DPT 1 , 2 and 3.

27. No need of booster dose
Catch up compaign for older age group is important in intermediate and low endemicity area.
Catch up compaign for infants and young children is important in high endemicity area.
Other target group for catch up strategy can be high risk group.
GACVs confirms excellent safety profile.
WHO recommends all countries should develop goal for HBV control according to their epidemiological situation

28. References
Park k., text book of preventive and social medicine, 20th edition page no
Manson’ text book tropical disease
Maxcy- rosaneu- last text book of public health
heahttp:// en/index.htmllth
/index.html

29. thank you