Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

HEPATITIS B
     
     Hepatitis B is a common STD. Sexual transmission accounts for
an estimated one-third to two-thirds of the estimated 200,000 to
300,000 new HBV infections that occurred annually in the United
States during the past 10 years. Of persons infected as adults, 6%-
10% become chronic HBV carriers. These persons are capable of
transmitting HBV to others and are at risk for developing fatal
complications. HBV leads to an estimated 5,000 deaths annually in
the United States from cirrhosis of the liver and hepatocellular
carcinoma.

     The risk of perinatal HBV infection among infants born to
HBV-infected mothers ranges from 10% to 85%, depending on the
mother's hepatitis B e antigen status. Infected newborns usually
become HBV carriers and are at high risk for developing chronic
liver disease.

Prevention
     
     Infection of both adults and neonates can be readily prevented
with a safe and effective vaccine that has been used in the United
States for more than 10 years. Universal vaccination of newborns is
now recommended (17). The use of hepatitis B immune globulin (HBIG)
combined with vaccination can prevent infection among persons
exposed sexually to HBV if administered within 14 days of exposure.

Vaccination Eligibility
     
     Persons known to be at high risk for acquiring HBV (e.g.,
persons with multiple sex partners, sex partners of HBV carriers,
or injecting drug users) should be advised of their risk for HBV
infection (as well as HIV infection) and the means to reduce their
risk (i.e., exclusivity in sexual relationships, use of condoms,
avoidance of nonsterile drug injection equipment, and HBV
vaccination).


     Selected high-risk groups for which HBV vaccination is
recommended by the ACIP include the following persons:

--   Sexually active homosexual and bisexual men,

--   Men and women diagnosed as having recently acquired another
     STD,

--   Persons who have had more than one sex partner in the
     preceding 6 months.

     Such persons should be vaccinated unless they are immune to
HBV as a result of past infection or vaccination. Refer to
Hepatitis B Virus: A Comprehensive Strategy for Eliminating
Transmission in the United States Through Universal Child
Vaccination, Recommendations of the Advisory Committee on
Immunization Practices (ACIP) (17).

Screening for Antibody Versus Vaccination Without Screening
     
     The prevalence of past HBV infection among sexually active
homosexual men and among injecting drug users is high. Serologic
screening for evidence of past infection before vaccinating members
of these groups may be cost-effective, depending on the relative
costs of laboratory testing and vaccine. Among those attending STD
clinics, it may be cost-effective to screen older persons for past
infection. During a recent study of 2,000 STD clinic patients who
accepted HBV vaccination, 28% of those greater than or equal to 25
years of age had evidence of past infection, whereas only 7% of
persons less than 25 years of age had evidence of past infection.
Past infection with HBV can be detected with a serologic test for
antibody to the hepatitis B core antigen (anti-HBc). Immunity can
be demonstrated by a test for antibody to the hepatitis B surface
antigen (anti-HBs). The HBV carrier state can be detected by a test
for HBsAg. If only a test for anti-HBc is used to screen for
susceptibility to infection, persons immune because of prior
vaccination will be falsely classified as susceptible. If only a
test for anti-HBs is used, carriers will be falsely classified as
susceptible.

Vaccination Schedules

     The usual vaccination schedule is three doses of vaccine at 0,
1, and 6 months. An alternative schedule of 0, 1, 2, and 12 months
also has been approved for one vaccine. The dose is 1 mL for
adults, which must be administered IM in the deltoid -- not in a
buttock. For persons 11-19 years of age, the dose is either 0.5 or
1 mL, depending on the manufacturer of the vaccine.

Management of Persons Exposed to HBV
     
     Susceptible persons exposed to HBV through sexual contact with
a person who has acute or chronic HBV infection should receive
postexposure prophylaxis with 0.06 mL/kg of HBIG in a single IM
dose within 14 days of their last exposure; early administration
may be more effective. HBIG administration should be followed by
the standard three-dose immunization series with HBV vaccine
beginning at the time of HBIG administration.

Special Considerations

Pregnancy -
     Pregnancy is not a contraindication to HBV or HBIG vaccine
administration.

HIV Infection -
     Among HIV-infected persons, HBV infection is more likely to
lead to chronic HBV carriage. HIV infection also impairs the
response to HBV vaccine. Therefore, HIV- infected persons who are
vaccinated should be tested for anti-HBs 1-2 months after the third
vaccine dose. Revaccination with one or more doses should be
considered for those who do not respond to vaccination initially.
Those who do not respond to additional doses should be advised that
they may remain susceptible.

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