[MCOH-EH] [EXTERNAL] Re: Incompletely Vaccinated HepB & Immunity Titers

[Hodgson, Michael - OSHA]

Thee are some old data suggesting another few percent respond to two subcutaneous doses.  Years ago, Denise Cardo, MD, from CDC’s CHQA, agreed that such off-label usage was appropriate.  I’ve been out of operations in health care since April 2012 (ouch, that is a long time), but until then that was pretty standard practice within VHA’s system

I wonder whether someone who’s been around can comment on that approach.  Is it still done?

Michael Hodgson

From: MCOH-EH <mcoh-eh-bounces at mylist.net> On Behalf Of Lanzi, Maria
Sent: Wednesday, July 11, 2018 8:20 AM
To: MCOH/EH <mcoh-eh at mylist.net>
Subject: Re: [MCOH-EH] [EXTERNAL] Re: Incompletely Vaccinated HepB & Immunity Titers

NO   After 6 documented doses they are considered true NON-Responders!   And their post exposure prophylaxis would include 2 doses of  HBIG (immunoglobulin) – see MMWR.

There is off label use of Twinrix, doubling the dose, etc to boost a response, but that is not currently recommended.

Maria

From: MCOH-EH [mailto:mcoh-eh-bounces+maria.lanzi=va.gov at mylist.net] On Behalf Of Deborah A. Pruim via MCOH-EH
Sent: Wednesday, July 11, 2018 8:13 AM
To: MCOH/EH
Cc: Deborah A. Pruim
Subject: Re: [MCOH-EH] [EXTERNAL] Re: Incompletely Vaccinated HepB & Immunity Titers

Wondering what we should do with non-converters?  I have a few employees who have had 2 documented rounds of Hep B vaccine (6 doses per routine protocol) and still test negative for antibodies.  Booster injections of vaccine do not help.  Thoughts?
Thanks,
Debbie
Deborah Pruim, RN, MSN, APN, CNS
Employee Health Services
Little Company of Mary Hospital
2800 W. 95th Street
Evergreen Park, IL  60805
Monday – Friday
6:30am-3pm
Phone:  708-229-5623
Fax:  708-229-6618
dpruim at lcmh.org<mailto:dpruim at lcmh.org>
[cid:image001.png at 01D2A32C.E73F4EA0]



From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Lanzi, Maria
Sent: Wednesday, July 11, 2018 7:06 AM
To: MCOH/EH
Cc: fldocstu at aol.com<mailto:fldocstu at aol.com>
Subject: Re: [MCOH-EH] [EXTERNAL] Re: Incompletely Vaccinated HepB & Immunity Titers

Good morning,

You raise good points.   And most of us would follow our clinical judgement, but the issue becomes more complicated in post-exposure prophylaxis.
In summary:
The latest CDC MMWR released January 12, 2018 states that without 3 documented doses long term immunity cannot be ensured as vaccine induced HbsAb wane over time.
Given the fact that most of us deal with the issues as you stated below on a daily basis, it has become a clinical judgement decision and clinicians operate differently.    Since Hep B vaccine is cell-mediated immunity, a rapid antibody response in a potential positive exposure is critical. The titer on pre-hire testing is valid, just unable to ensure if it would be long term.   If a needlestick occurs  later in time (say 10 years after pre-hire), the possibility of a negative HbsAb would complicate the clinical decision process.

For those “ancient HCP” like myself, having received the original pooled blood vaccine, some of us think it may have given us “longer and better” protection than the current recombinant vaccine – although with a higher risk of adverse reactions.   I have found  no studies to support this theory.   There was also, for many years, the thought that those HCP in higher risk categories (ie surgeons) should be tittered on a periodic basis.   While that is no longer recommended, again, many clinicians use clinical judgement.   One must also keep in mind that since 1994 when Hep B vaccine became universally recommended, that the overall risk  of contracting Hep B in certain age groups has decreased.

A very complicated topic with multiple approaches to interpretation.  Best practice is to ensure 3 documented appropriately administered doses with a positive titer 4-6 weeks after last dose.

Maria

Maria C. Lanzi, MS, MPH, ANP-BC, COHN-S, CTH
Nurse Practitioner/Program Coordinator
Employee Occupational Health
Corporal Michael J Crescenz Veterans Affairs Medical Center
3900Woodland Avenue
Philadelphia, PA 19104
Work:  215 823 5800 x 2592
Fax:  215 823 5968





From: MCOH-EH [mailto:mcoh-eh-bounces+maria.lanzi=va.gov at mylist.net] On Behalf Of Stuart Sandler via MCOH-EH
Sent: Tuesday, July 10, 2018 8:33 AM
To: mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>
Cc: fldocstu at aol.com<mailto:fldocstu at aol.com>
Subject: [EXTERNAL] Re: [MCOH-EH] Incompletely Vaccinated HepB & Immunity Titers

List,

I may be missing something, so ask for enlightenment.  If someone comes in knowing that they had the 3 series of HepB vaccine and you receive a positive HepBSAb titer on your pre-hire testing, why would you give a repeat series if the person cannot produce written documentation of the vaccines?  I received my vaccines many years ago and the institution is no longer available to ask for records, nor did we think of that at the time.  Would not the positive titer itself suffice for proof of immunity?  I have not been asked in the past by any employer or hospital for proof of vaccine, just proof of immunity.


And what do you do with a person who doesn't remember if they had ever been vaccinated (happens more times than I can count), yet has a sufficient HepBSAb titer?  It doesn't mean that they never received the series.  Then, too, what do you do if the person received two vaccines only, but has a significantly positive titer?  Why would you give them the third, especially if it had been a while since the first two? For example, I became significantly symptomatic after my second vaccine (OK, it WAS in the stone ages at the early start of vaccinations and they weren't as refined as they are curently), so a titer was done prior to getting the third.  I had a high Ab titer, so it was decided that I had been properly immunized and that the risks of having the third were outweighed by the possible of a worsened reaction.  BTW, I had a documented 0 titer prior to the vaccine series.

Just curious.

Stuart A. Sandler, DO


-----Original Message-----

Today's Topics:

1. Re: #ExtMail# Incompletely Vaccinated HepB & Immunity Titers
AND ? requiring Hepatitis B vaccination for employees?
(Schweitzer, Kit)


----------------------------------------------------------------------

Message: 1
Date: Mon, 9 Jul 2018 22:32:14 +0000
From: "Schweitzer, Kit" <KSchweitzer at peacehealth.org<mailto:KSchweitzer at peacehealth.org>>
To: "MCOH/EH" <mcoh-eh at mylist.net<mailto:eh at mylist.net>>
Subject: Re: [MCOH-EH] #ExtMail# Incompletely Vaccinated HepB &
Immunity Titers AND ? requiring Hepatitis B vaccination for employees?
Message-ID:
<MWHPR10MB1488B9A500DFCC0A0C27A544B1440 at MWHPR10MB1488.namprd10.prod.outlook.com<mailto:MWHPR10MB1488B9A500DFCC0A0C27A544B1440 at MWHPR10MB1488.namprd10.prod.outlook.com>>

Content-Type: text/plain; charset="us-ascii"

We require documentation of 3 Hep B vaccs AND positive titer to ensure life long immunity as recommended by CDC. We start the series over if they don't have documentation and only a titer. If documentation and no titer, we draw a titer.
Thank you.
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://mylist.net/archives/mcoh-eh/attachments/20180711/665bd9ba/attachment-0001.html>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image001.png
Type: image/png
Size: 12997 bytes
Desc: image001.png
URL: <https://mylist.net/archives/mcoh-eh/attachments/20180711/665bd9ba/attachment-0001.png>