What are the guidelines for the management of occupational exposure to hepatitis B virus?

Hepatitis B is an inflammatory disease of the liver caused by Hepatitis B viral infections (HBV). The risk for transmission of HBV is well recognized after exposure to infected blood or body fluids. The most common modes of HBV transmission in a dental office include needle stick injuries and other percutaneous injuries. Exposure prevention remains the key strategy to minimize occupational HBV infections; however, if the exposure occurs a proper post-exposure management is of the utmost importance. HBV Post Exposure Prophylaxis (PEP) recommendations are summarized below:

PEP Recommendations

If the status of the source person is Hepatitis B Surface Antigen (HBsAg) positive

• An unvaccinated Health Care Worker (HCW) or HCW who is in the process of being vaccinated but has not completed the full series yet, should take 1 dose of HBIG (0.06 mL/kg IM) as soon as possible, preferably within 24 hours followed by hepatitis B vaccination series.
• Vaccinated HCW, who is a known responder, does not require any treatment.
• Vaccinated HCW, who is a known non-responder should take 1 dose of HBIG followed by a complete series of hepatitis B vaccine, OR 2 doses of HBIG should be taken with second dose 1 month after the first dose. For a known non-responder HCW who has already completed the second 3 dose vaccine series, 2 doses of HBIG are
• Vaccinated HCW whose response is unknown should be tested for anti-HBsAg, if response is inadequate (<10 mU/mL), 1 dose of HBIG along with hepatitis B vaccine booster dose should be given. If an adequate response is present, no treatment is required.

 If the status of the source person is HBsAg negative

• Unvaccinated HCW should undergo complete series of HBV vaccination.
• Vaccinated HCW who is a known responder does not require any treatment.
• Vaccinated HCW who is a known non-responder does not require any treatment.
• Vaccinated HCW whose response is unknown does not require any treatment.

If the status of the source person is unknown

• Unvaccinated HCW should undergo the complete series of HBV vaccination.
• Vaccinated HCW, who is a known responder, does not require any treatment.
• If the source person is suspected to be of high risk, vaccinated HCW, who is a known non-responder should take 1 dose of HBIG followed by a complete series of hepatitis B vaccination OR 2 doses of HBIG should be taken with second dose 1 month after the first dose. For a known non-responder HCW who has already completed the second 3 dose vaccine series, 2 doses of HBIG are recommended..
• Vaccinated HCW, whose response is unknown, should be tested for anti-HBsAg; if response is adequate no treatment is required. However, if response is inadequate (<10 mU/mL), a hepatitis B vaccine booster dose should be given and the titer should be rechecked in 1-2 months.

Whenever Hepatitis B Immune Globulin (HBIG) or HBV vaccination is indicated, it should be initiated within 24 hours of exposure for maximum effectiveness and no later than 7 days. Both HBIG and HBV vaccination can be administered simultaneous at separate sites of the body.

References

1. Little, Falace, Miller, Rhodus. Dental management of the medically compromised patient. 8th ed. St. Louis: Mosby Elsevier; 2008.
2. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001; 50(No. RR-11).