• Patients with impaired renal function +/- dialysis are at increased risk of Hepatitis B infection. In addition they often have a diminished immune response to the Hep B vaccine. The cause of this is not completely understood. It is well documented that the earlier a patient is immunised in the disease progression, the better response and long term protection they will have.
  • We have defined impaired renal function as Chronic kidney disease (CKD) 4-5 (GFR <30ml/min)
  • Hepatitis B is a blood borne virus, which can result in chronic infection, cirrhosis, fulminant liver failure and hepatocellular carcinoma. As chronic Hep B carrier can also infect others, through e.g. sexual contact, pregnancy (antenatal), and needle stick (see RCH guidelines)
  • It has been documented that by vaccinating patients with impaired renal function with a combination Hepatitis A and B vaccine (Twinrix) seroconversion can be enhanced.(1)
  • The serological correlate for Hep B protection is a blood test measuring anti-Hep B surface antibodies (antiHBs). The serum immune response should be measured 1-month post a vaccine dose. A level >10IU/ml is considered protective.
  • It is necessary to determine and document previous immunisation history. This information can be obtained via personal health records or the Australian Childhood Immunisation Register (ACIR)- for children < 7-years.  In addition, vaccines administered at RCH (all ages) are entered into the ImPs database. [Contact RCH Immunisation service for details Tele: 1300 882 924 (option 2)]

Table 1: Current Hepatitis B Immunisation Schedule as per National Immunisation Program

Vaccine brand Age of vaccine recipient Volume of dose Number of doses required Recommended schedule intervals
Infant Schedule
H-B Vax II
(paediatric formulation)
Birth 0.5ml 1 Within 7-days of birth
(no catch up required if not given by this time)
Combination Hepatitis B vaccine:
Infanrix Hexa
(DTPa-Hib-IPV-Hep B)
2, 4 and 6 months of age 0.5ml 3 1st dose: 2 months of age
2nd dose: 4 months of age
(2 months after 1st dose)
3rd dose: 6 months of age (must be 2 months after 2nd dose and the child aged greater than 24 weeks of age)

# The first dose of Infanrix Hexa can be given from 6 weeks of age. The subsequent doses can then be given at 4 months and 6 months of age.
Note:

  • Comvax (Hib-Hep B combined vaccine) was used from 2000-2008
  • Adolescent Hep B vaccine program (catch-up for those who did not receive Hepatitis B course in infancy) finished in 2013

Immunisation and Management Plan of Patients with Impaired Renal Function

  • Ensure previously up to date as per NIP schedule
  • Do serology at diagnosis for baseline antiHBsAby

Table 2: Recommended vaccine schedule if non-Hep B immune – using combined Hepatitis A and B vaccine [Twinrix Adult 720/20]

Age at diagnosis Recommended vaccine:
Twinrix (720/20)

Serology

<12 months 2 dose course
1st dose: given at 12 months of age
2nd dose*: given at 18 months of age
At diagnosis
1 month post 2nd dose of Twinrix
Every 12 months thereafter
 >12 months If baseline titre at diagnosis is >10IU/ml: 2 dose course
1st dose: given on day 0
(first day of vaccination)
2nd dose: 6 months after the first dose
At diagnosis
1 month post 2nd dose of Twinrix (month 7)
Every 12 months thereafter
If baseline titre at diagnosis is <10IU/ml: 3 dose course
1st dose: given day 0
(first day of vaccination)
2nd dose: 1 month after the first dose
3rd dose: 6 months after the first dose
At diagnosis
1 month post 2nd dose of Twinrix (month 2)
1 month post 3rd dose of Twinrix (month 7)
Every 12 months thereafter

# Twinrix (720/20) is a combination Hepatitis A and B vaccine. It contains 720 ELISA units of HAV antigens and 20mcg of Hepatitis B surface antigen protein. Each dose is 1.0ml given intramuscularly
*doses must be separated by 6 months

  • If titre remains <10IU/ml post above immunisation plan, consider alternative Hepatitis B vaccine brands or route of administration (e.g. intradermal)
  • RCH Immunisation Clinic every Tuesday AM to discuss issues and concerns (referral required- Tele 1300 882 924 [option 1])

Reference:

Tung J, Carlisle E, Smieja M, Kim PT, Lee CH. A Randomized Clinical Trial of Immunization With Combined Hepatitis A and B Versus Hepatitis B Alone for Hepatitis B Seroprotection in Hemodialysis Patients. Am J Kidney Dis. 2010;56(4):713-9.

Reviewed by: Nigel Crawford (Paediatrician, The Royal Children’s Hospital, Melbourne)
Date: July 2014
Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.
You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 



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