[MCOH-EH] #ExtMail# MCOH-EH Digest, Vol 252, BBP exposures

[Grubbs, Scott]

I attach excerpts of two CDC documents regarding this subject, which indicate the presence of protective immunity *after less than three vaccinations.*  Please note the term "long term immunity" in the correction (first document).  The second document (abstracted from the link in the correction) indicates the percentage of vacinees who have "protective antibody response" after 1, 2 or 3 vaccinations. 

Obviously, if the positive titer in an individual who only had two vaccinations was obtained 10 years ago, the concern (regarding long term protection) would justify repeating the vaccination; however, if it is obtained at the time of HBV exposure and shows protective immunity, then it doesn't make sense to give Immune globulin other than for medicolegal reasons; perhaps to the employee's harm. Obtaining a current titer while giving a third vaccine (and immune globulin if a negative current  HBsAb titer) would make sense and provide more certainty of long term immunity for future exposures.  

Again, only my opinion, but I think it is based on solid evidence.  

The 2013 reference below evidently does not take into account the information above, which is also from the CDC.  

Odd, the reference below indicates "HCP exposed to a source patient who is HBsAg-positive or has unknown HBsAg status do not need to take special precautions to prevent secondary transmission during the follow-up period; however, they should refrain from donating blood, plasma, organs, tissue, or semen (1). The exposed HCP does not need to modify sexual practices or refrain from becoming pregnant (1). If an exposed HCP is breast feeding, she does not need to discontinue (1). No modifications to an exposed HCP's patient-care responsibilities are necessary to prevent transmission to patients based solely on exposure to a source patient who is HBsAg-positive or has unknown HBsAg status."  Does unprotected sex not = semen donation?

Don't like to contradict official guidance, but it is  self-contradictory.

Scott Grubbs, MD
WorkWell Occupational Health
Greenville, SC



-----Original Message-----
From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Harriman, Kathleen (CDPH-CID-DCDC-IMM)
Sent: Tuesday, November 14, 2017 3:01 PM
To: mcoh-eh at mylist.net
Subject: #ExtMail# [MCOH-EH] MCOH-EH Digest, Vol 252, BBP exposures

The CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, Recommendations and Reports, December 20, 2013 / 62(RR10);1-19 (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm) states that anti-HBs greater than or equal to 10 mIU/mL should only be used as a correlate of protection for HCP with documentation of a complete HepB vaccine series.  HCP who lack documentation of a dose or doses of HepB vaccine should be considered unvaccinated for those dose(s) for which documentation is lacking.  Please refer to Table 2 in the above referenced MMWR for the post-exposure management protocol, including for unvaccinated or incompletely vaccinated HCP.    

Kathleen Harriman
Immunization Branch
California Department of Public Health
kathleen.harriman at cdph.ca.gov


Date: Tue, 14 Nov 2017 18:18:46 +0000
From: "Grubbs, Scott" <Scott_Grubbs at bshsi.org>
To: MCOH/EH <mcoh-eh at mylist.net>
Subject: Re: [MCOH-EH] BBP exposures

While the person does need to complete the series for long term immunity assurance, for the exposure of the moment, it would seem reasonable to think that they have the right antibodies to deal with it.  However, I am not an ID doc, so that is just my opinion.
Scott Grubbs, MD
WorkWell Occupational Health
Greenville, SC

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Tim Crump
Sent: Monday, November 13, 2017 12:43 PM
To: MCOH/EH
Subject: Re: [MCOH-EH] BBP exposures

I would be interested in knowing how people are testing workers who have not completed the Hepatitis B immunization series.  Our staff who sustain a needle stick or other BBFE afterhours are seen in the ED, where they do not necessarily know their immunization status.  They test everyone w/ HepB sAb.  My understanding of CDC recommendations is that workers who have not completed the series should be tested w/ HepB core Ab, and that surface antibody is uninterpretable if the immu series is not complete.  So my question is, can the HepB surface antibody be used as a marker of immunity to Hep B at that moment, or is it misleading and should be put aside when the immu series is incomplete, potentially making a worker a candidate for HBIG?  Thanks for any insight, Tim

Tim Crump, MSN, FNP
Family Nurse Practitioner
Multnomah Pavilion 1 SE, Suite 1110
Occupational Health
Healthcare Human Resources

Oregon Health & Science University
3181 SW Sam Jackson Park Rd
Mail code: UHN 89
Portland, OR 97239-3098
Department Phone: 503-494-5271
Office Phone: 503-346-1152
Fax: 503-494-4457
Email: crumpt at ohsu.edu<mailto:crumpt at ohsu.edu>


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