This is the current release of the guideline.

This guideline updates a previous version: CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(No. RR-13).

Hepatitis B virus (HBV) infection

To increase hepatitis B vaccination of adults at risk for hepatitis B virus infection

Adults at risk for hepatitis B virus infection

Not stated

Not stated

Not applicable

Not stated

In response to continuing low rates of hepatitis B vaccination among adults at risk for hepatitis B virus (HBV) infection, the Advisory Committee on Immunization Practices (ACIP's) Hepatitis Vaccines Work Group met multiple times during October 2004 to September 2005 to review previous guidelines and make recommendations for improving vaccination coverage in adults. The work group examined the progress made since 1991 in implementing the U.S. strategy to eliminate HBV transmission (e.g., vaccination coverage data and hepatitis B disease rates), surveillance data on missed opportunities for hepatitis B vaccination among adults with acute hepatitis B, and results of cost-effectiveness analyses. In addition, demonstration projects conducted in settings in which a high proportion of clients were at risk for HBV infection identified the components of successful adult hepatitis B vaccination programs and ongoing challenges to implementing adult hepatitis B vaccination.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

In January 2005, the proposed recommendations were posted online for public comment. In May 2005, Centers for Disease Control and Prevention convened a meeting of external consultants, including researchers, physicians, state and local public health professionals, immunization program directors, and directors of viral hepatitis, sexually transmitted disease, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevention programs, to obtain input into the draft recommendations and consider the feasibility of the recommended strategies. In October 2005, the revised recommendations were approved by Advisory Committee on Immunization Practices (ACIP).

Note from the Centers for Disease Control and Prevention (CDC) and the National Guideline Clearinghouse (NGC): On September 19, 2008 the CDC released updated guidelines on hepatitis B. For more information see the NGC summary Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection.

This report updates Advisory Committee on Immunization Practices (ACIP) recommendations published previously for hepatitis B vaccination of adults (MMWR 1991;40[RR-13]). The primary changes from previous recommendations are as follows:

• In settings in which a high proportion of persons are likely to be at risk for hepatitis B virus (HBV) infection (e.g., sexually transmitted disease/human immunodeficiency virus –STD/HIV] testing and treatment facilities, drug-abuse treatment and prevention settings, health-care settings targeting services to injection-drug users, health-care settings targeting services to men who have sex with men, and correctional facilities), ACIP recommends universal hepatitis B vaccination for all adults who have not completed the vaccine series.
• In primary care and specialty medical settings, ACIP recommends implementation of standing orders to identify adults recommended for hepatitis B vaccination and administer vaccination as part of routine services. To ensure vaccination of adults at risk for HBV infection who have not completed the vaccine series, ACIP recommends the following implementation strategies:
  • Provide information to all adults regarding the health benefits of hepatitis B vaccination, including risk factors for HBV infection and persons for whom vaccination is recommended.
  • Help all adults assess their need for vaccination by obtaining a history that emphasizes risks for sexual transmission and percutaneous or mucosal exposure to blood.
  • Vaccinate all adults who report risks for HBV infection.
  • Vaccinate all adults requesting protection from HBV infection, without requiring them to acknowledge a specific risk factor.

Recommendations for Hepatitis B Vaccination of Adults

Hepatitis B vaccination is recommended for all unvaccinated adults at risk for HBV infection and for all adults requesting protection from HBV infection (see Box below titled "Adults Recommended to Receive Hepatitis B Vaccination"). Acknowledgment of a specific risk factor should not be a requirement for vaccination.

Box. Adults Recommended to Receive Hepatitis B Vaccination

Providers should select the vaccine schedule they consider necessary to achieve completion of the vaccine series (see Table 2 in the original guideline document and the Box below titled "Hepatitis B vaccine schedules for adults [aged >20 years]").

Box. Hepatitis B Vaccine Schedules for Adults (Aged >20 years)*

Public health programs and primary care providers should adopt strategies appropriate for the practice setting to ensure that all adults at risk for HBV infection are offered hepatitis B vaccine (see Box 6 in the original guideline document and "Description of the Implementation Strategy" field below).

See the following appendices in the original guideline document for further information:

• Appendix A: Immunization management issues 
• Appendix B: Postexposure prophylaxis to prevent hepatitis B virus infection 
• Appendix C: Identification and management of hepatitis B surface antigen (HBsAg)-positive persons 

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus infection and its consequences, including cirrhosis of the liver, liver cancer, liver failure, and death.

Hepatitis B vaccination is contraindicated for persons with a history of hypersensitivity to yeast or any vaccine component. Despite a theoretic risk for allergic reaction to vaccination in persons with allergy to Saccharomyces cerevisiae (baker's yeast), no evidence exists to document adverse reactions after vaccination of persons with a history of yeast allergy.

Persons with a history of serious adverse events (e.g., anaphylaxis) after receipt of hepatitis B vaccine should not receive additional doses. As with other vaccines, vaccination of persons with moderate or severe acute illness, with or without fever, should be deferred until illness resolves. Vaccination is not contraindicated in persons with a history of multiple sclerosis, Guillain-Barré syndrome, autoimmune disease (e.g., systemic lupus erythematosus or rheumatoid arthritis), or other chronic diseases.

In settings in which a high proportion of persons have risk factors for hepatitis B virus (HBV) infection (see Box below titled 'Settings In Which Hepatitis B Vaccination Is Recommended for All Adults'):

• All adults should be assumed to be at risk for HBV infection and should be offered hepatitis B vaccination if they have not completed a licensed hepatitis B vaccine series.
• Health-care providers should implement standing orders to administer hepatitis B vaccine as part of routine services to adults who have not completed the vaccine series and make hepatitis B vaccination a standard component of evaluation and treatment for sexually transmitted diseases (STDs) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (see Table 3 in the original guideline document).
• When feasible, hepatitis B vaccination should be offered in outreach and other settings in which services are provided to persons at risk for HBV infection (e.g., needle-exchange programs, HIV testing sites, HIV prevention programs, and homeless shelters).

Box Settings In Which Hepatitis B Vaccination Is Recommended for All Adults

In primary care and specialty medical settings (e.g., physician's offices, family planning clinics, community health centers, liver disease clinics, and travel clinics), providers should implement standing orders to identify adults recommended for hepatitis B vaccination and administer vaccination as part of routine services. To ensure vaccination of persons at risk for HBV infection, health-care providers should:

• Provide information to all adults regarding the health benefits of hepatitis B vaccination, including the risk factors for HBV infection and persons for whom vaccination is recommended.
• Help all adults assess their need for vaccination by obtaining a history that emphasizes risks for sexual transmission and percutaneous or mucosal exposure to blood.
• Administer hepatitis B vaccine to adults who report risk factors for HBV infection.
• Provide hepatitis B vaccine to all adults requesting protection from HBV infection without requiring acknowledgment of a specific risk factor.

Occupational health programs should:

• Identify all staff whose work-related activities involve exposure to blood or other potentially infectious body fluids in a health-care, laboratory, public safety, or institutional setting (including employees, students, contractors, attending clinicians, emergency medical technicians, paramedics, and volunteers).
• Provide education to staff to encourage vaccination.
• Implement active follow-up, with reminders to track completion of the vaccine series among persons receiving vaccination.
• Provide appropriate postvaccination testing (see Appendix A in the original guideline document).

Providers in all settings in which hepatitis B vaccine is provided should:

• Assess patients' needs for other vaccines recommended for adults (schedule available at http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm ) and administer these vaccines at the same office visit at which hepatitis B vaccine is administered.
• Identify and vaccinate all susceptible household, sex, and needle-sharing contacts of HBsAg-positive persons, and provide HBsAg-positive persons with appropriate referrals for counseling and medical management (see Appendix C in the original guideline document)
• Provide culturally appropriate materials to educate adults about hepatitis B and the importance of vaccination (available at http://www.cdc.gov/ncidod/diseases/hepatitis/b/index.htm#materials ).
• Offer vaccination in a way that is accessible, convenient, and flexible for patients.
• Be familiar with Advisory Committee on Immunization Practices (ACIP's) general recommendations on immunization, which provide technical guidance regarding common immunization concerns of health-care providers.
• Give persons who are eligible for vaccination a copy of the most current vaccine information statement for hepatitis B vaccine, as required by federal law (see Appendix A in the original guideline document, 'Hepatitis B Vaccine Dose and Administration')
• Institute methods to identify persons with a history of vaccination (see Appendix A in the original guideline document, 'Unknown or Uncertain Vaccination Status')
• Provide vaccinated persons with a personal record card documenting receipt of vaccination (available at http://www.immunize.org/guide/aov21_appb_record.pdf ).
• Develop tracking and reminder systems to ensure completion of the vaccine series (descriptions of such systems are available at http://www.cdc.gov/vaccines/recs/immuniz-records.htm ).
• Report adverse events to Vaccine Adverse Events Reporting System (VAERS) using report forms and assistance available from CDC at telephone 1-800-822-7967 or from VAERS at http://www.vaers.hhs.gov/ .
• Be familiar with billing and reimbursement guidelines for hepatitis B vaccination (available at http://www.ama-assn.org/ama1/pub/upload/mm/36/ama_hep_coding_trifo.pdf ).

Public health agencies and medical organizations should educate providers about the benefits of hepatitis B vaccination for their patients and methods to implement and support hepatitis B vaccination services in their settings and practices. Health departments and community-based organizations should increase awareness of the benefits of hepatitis B vaccination, particularly among persons at increased risk for HBV infection. Educational materials are available at http://www.cdc.gov/ncidod/diseases/hepatitis/index.htm .

Health departments are encouraged to implement adult immunization registries to track the receipt of hepatitis B vaccine in all settings in which adults are vaccinated. Information on immunization registries is available at http://www.cdc.gov/vaccines/recs/immuniz-records.htm .

Although hepatitis B vaccination programs aim to achieve the highest possible rate of vaccine series completion, concerns regarding completion of the hepatitis B vaccine series should not preclude initiation of hepatitis B vaccination. Each dose of vaccine confers some protection against HBV infection. Vaccine immunogenicity is not decreased by lengthened intradose intervals, and the second and third doses can be administered during subsequent health-care visits outside of the recommended vaccine schedule.

Not applicable: The guideline was not adapted from another source.

United States Government

Not stated

Prepared by: Eric E. Mast, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Cindy M. Weinbaum, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Anthony E. Fiore, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Miriam J. Alter, PhD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Beth P. Bell, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Lyn Finelli, DrPH, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Lance E. Rodewald, MD, Immunization Services Division, National Center for Immunization and Respiratory Diseases (proposed); John M. Douglas, Jr., MD, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); Robert S. Janssen, MD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); John W. Ward, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed)

Centers for Disease Control and Prevention (CDC), their planners, and content experts wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use.

This is the current release of the guideline.

This guideline updates a previous version: CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(No. RR-13).

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site:

• HTML Format 
• Portable Document Format (PDF) 

Print copies: Available from the Centers for Disease Control and Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

Continuing Education activity is available from the Centers for Disease Control and Prevention (CDC) Web site .

None available

This NGC summary was completed by ECRI on February 8, 2007.

No copyright restrictions apply.