Tag: titers

What to Do If Your Child Is Exposed to Hepatitis B

Hepatitis B is a vaccine-preventable disease.

“In the United States, based on national health surveys, there are approximately 850,000 persons living with chronic HBV infection. However, estimates based on other methods and data yield estimates as high as 1.29 to 2.2 million persons with chronic HBV infection.”

Manual for the Surveillance of Vaccine-Preventable Diseases

That doesn’t mean that your child can’t be exposed at some point though.

What to Do If Your Child Is Exposed to Hepatitis B

Hepatitis B is mainly spread through blood and body fluids, which is why some folks consider the hepatitis B vaccine an STD vaccine.

“If you are concerned that you might have been exposed to the Hepatitis B virus, call your health professional or your health department. If a person who has been exposed to Hepatitis B virus gets the Hepatitis B vaccine and/or a shot called “HBIG” (Hepatitis B immune globulin) within 24 hours, Hepatitis B infection may be prevented.”

CDC on Hepatitis B FAQs for the Public

It is also possible to get hepatitis B from exposure from an infected family member or caretaker, or much more rarely, in a daycare or school setting.

So what do you do if your child is exposed to hepatitis B?

It depends.

Kids should complete the three dose hepatitis B vaccine series by the time they are 18 months old.
Kids should complete the three dose hepatitis B vaccine series by the time they are 18 months old.

Not surprisingly, one of the biggest factors that will determine what needs to be done is whether or not your child has completed a three dose hepatitis B vaccine series.

First things first though.

Before going any further, you will want to confirm that the person that exposed your child actually has hepatitis B (has a positive HBsAg level).

Next, confirm that it was a real exposure, which the AAP Red Book defines as “a discrete, identifiable percutaneous (eg, needlestick, laceration, bite or nonintact skin), mucosal (eg, ocular or mucous membrane), or sexual exposure to blood or body fluids.”

Keep in mind that the hepatitis B virus is not spread by casual contact, like hugging, kissing, holding hands, or even sharing silverware. It can be spread by having unprotected sex or sharing needles with someone who is infected, but also by coming into contact with open sores, getting bitten, sharing personal-care items, sharing chewing gum, or an unintentional needle stick at a doctor or dentist office or from a needle picked up in the community (park, playground, or street, etc.).

And of course, a newborn baby can be exposed if their mother has hepatitis B.

Biting and Hepatitis B

Young kids, especially toddlers, often go through a biting phase.

Do you have to worry about hepatitis B every time your child gets bit or bites someone?

Fortunately, no.

If any of the kids involved include one that is known to have hepatitis B, then talk to your pediatrician and follow the exposure guidelines.

Keep in mind that one of the reasons we don’t have to worry about these very low risk situations is because most kids are now vaccinated. There were more reports of kids and adults getting hepatitis B in unusual ways in the pre-vaccine era.

What to Do If Your Unvaccinated Child Is Exposed to Hepatitis B

If your unvaccinated child, or incompletely vaccinated child, is exposed to hepatitis B, you should talk to your pediatrician or local health department about starting post-exposure prophylaxis as soon as possible and preferably within 24 hours of the exposure (and not longer than 7), including:

  • a dose of HBIG
  • the first dose of hepatitis B vaccine, with plans to complete the three dose series as quickly as possible over the next 6 months

If you aren’t sure if the person had hepatitis B, then your unvaccinated child should likely just complete the three dose hepatitis B series without getting HBIG.

What to Do If Your Vaccinated Child Is Exposed to Hepatitis B

Unfortunately, if your vaccinated child is exposed to hepatitis B, you can’t simply assume that your child is protected and ignore the exposure. That is, unless your child has already had testing to confirm that he was a responder to the hepatitis B vaccine series – a HBsAb level of 10 or greater.

Since this titer test isn’t routinely done, your child will likely need a booster dose of the hepatitis B vaccine. A dose of HBIG isn’t needed.

If you aren’t sure if the person that exposed your child had hepatitis B, then your fully vaccinated child doesn’t need any additional treatment.

Getting Exposed to Hepatitis B in a Healthcare Setting

It should be noted that the guidelines are a little different and more aggressive if you are exposed in a healthcare setting vs your child having a nonoccupational exposure to hepatitis B.


There is probably more risk of getting infected from an occupational exposure where patients might be sick with hepatitis B. That’s why post-exposure testing on the exposed person is routinely done.

And since they are at risk for continued exposures, post-treatment testing, if required, to confirm a good response to the hepatitis B vaccine is also usually done.

What to Know About Getting Exposed to Hepatitis B

Hepatitis B exposures can come from more than just having sex or getting stuck with a needle. Learn what to do if your child is exposed to hepatitis B, especially if they aren’t already fully vaccinated and protected.

More on Getting Exposed to Hepatitis B

Did Your Hepatitis B Antibody Test Come Back Negative?

Hepatitis B can be prevented.Three doses of the hepatitis B vaccines have been shown to provide long lasting protection in most people.

Do you need to get your titers checked to make sure you are immune?

Usually not. Simply being fully vaccinated with the  vaccine is  good enough evidence that you are immune in most, but not all circumstances.

A few circumstances in which you might need to be tested can include:

  • a baby who was born to a HBsAg (hepatitis B surface antigen) mother
  • being a healthcare worker who has a job and who is in a work setting that puts them at higher risk for exposure to blood or body fluids from patients who are positive for HBsAg
  • being immunocompromised, so you are not sure if the vaccine is going to work, or patients requiring chronic dialysis
  • someone who has sex or shares needles with a person who has a chronic hepatitis B infection

The screening test for vaccine immunity that is done checks the persons level of anti-HBs (antibody to the hepatitis B surface antigen). It should be done one to two months after your last dose of hepatitis B vaccine, but not later.

“Persons determined to have anti-HBs concentrations of ≥10 mIU/mL after receipt of the primary vaccine series are considered immune, and the result should be documented. Immunocompetent persons have long-term protection and do not need further periodic testing to assess anti-HBs levels.”

CDC on Immunization of Health-Care Personnel

The alternative to screening healthcare workers after they complete their vaccination series is to do postexposure management. In this method, in the case of a needlestick or other blood or body fluid exposure, both the source patient and the health care worker are tested and postexposure prophylaxis is given as necessary.

Don’t pregnant women get tested for hepatitis B? They do, but not to see if they are immune from immunization. They routinely have a HBsAg test to see if they have a chronic hepatitis B infection, which can be passed on to their baby.

Other screening tests that can be done include anti-HBc (antibody to hepatitis B core antigen) and IgM anti-HBc (IgM subclass to hepatitis B core antigen). These two tests can help you figure out if a person has an acute infection or is immune from a past infection.

Non-Immune Hepatitis B Titer Levels

Why check the anti-HBs level?

Because of the devastating effects of chronic hepatitis B infections, it is good to have all of the information you can get to help prevent a possible infection if you are exposed to blood or body fluids while working.

Having a positive anti-HBs level, typically defined as a level of ≥10 IU/mL, means that you are immune and protected.

But what if your level is negative? What if your level is <10 IU/mL after you have already gotten three doses of hepatitis B vaccine?

Then you get another dose of hepatitis B vaccine and the level is checked again in one to two months. If it is still <10 IU/mL, then you get two more doses of hepatitis B vaccine and the level is checked again in one to two months.

If you are still negative after six or more doses of hepatitis B vaccine, then you are considered a non-responder. You would then require postexposure testing and possible prophylaxis if you are exposed to a patient’s blood or body fluids.

What If You Lost Your Hepatitis B Immunity?

There is a reason that they don’t recommend testing more than one to two months after your last dose of hepatitis B vaccine.

“Studies indicate that immunologic memory remains intact for at least 20 years and confers protection against clinical illness and chronic HBV infection, even though anti-HBs levels that once measured adequate might become low or decline below detectable levels. If one is challenged with HBV, people whose immune systems are competent will mount an anamnestic response and develop protective anti-HBs.”

Immunization Action Coalition on Hepatitis B Questions

It is known that anti-HBs levels can decrease over time.

Fortunately, this does not lead to waning immunity in typical circumstances. Because of an anamnestic response, the hepatitis B vaccine provides long lasting protection, even if your antibody levels appear to have dropped.

Avoiding Hepatitis B

Since health care workers should practice universal precautions whether or not they are immune to hepatitis B, being a non-responder isn’t going to change how you do things too much.

Plus, there are other diseases that are not yet vaccine preventable that you could get if you are stuck with a needle, so you are hopefully still very careful, no matter how immune you are to hepatitis B.

Still, it is very nice to have one less thing to worry about in this situation.

“Unvaccinated or incompletely vaccinated persons who experience a workplace exposure from persons known to be HBsAg-positive should receive 1 dose of hepatitis B immune globulin HBIG (i.e., passive vaccination) as soon as possible after exposure (preferably within 24 hours).”

CDC on Immunization of Health-Care Personnel

If you are a non-responder and and are exposed to hepatitis B, then one thing that is different is that you will likely require two doses of HBIG (hepatitis B immune globulin) for protection. Others can get one dose of HBIG and can repeat the hepatitis B vaccine. Those who are fully vaccinated and known to be immune likely won’t have to do anything to protect themselves from hepatitis B, although each incident should be investigated to make sure.

But it is not just healthcare workers who are at risk for accidental needlesticks. What if a healthcare worker sticks themselves and then you or your child? Or what if your child gets stuck with a discarded needle at the park?

What to Know About Hepatitis B Titers

Get vaccinated and follow the latest guidelines if you are exposed to hepatitis B, especially if you are a non-responder to the vaccine with low titer levels.

More on Hepatitis B Titers and Immunity

Did Your Rubella Titer Come Back Negative?

Two doses of the MMR vaccines give the great majority of people long lasting immunity to measles, mumps, and rubella. Well, measles and rubella anyway. Unfortunately, the mumps part of the vaccine has some issues with waning immunity.

Do you need to get your titers checked to make sure you are immune?

Usually not. Simply being fully vaccinated with the MMR vaccine is  good enough evidence that you are immune in most, but not all circumstances

Getting or being pregnant is one of those circumstances in which it is important to know for sure. It is really one of the only circumstances. Health care works are no longer routinely tested after they are vaccinated, as proof of vaccination is good evidence of immunity for the MMR vaccine.

The American College of Obstetricians and Gynecologists recommends that all pregnant women be screened for rubella.
The American College of Obstetricians and Gynecologists recommends that all pregnant women be screened for rubella.

That screening test is a rubella serum IgG levels or as it is more commonly known as, a titer level.

Non-Immune Rubella Titers

Why check it?

Because of the devastating effects of congenital rubella syndrome, all pregnant women are screened early in their pregnancy.

Babies with congenital rubella syndrome may have cataracts and many other birth defects.
Babies with congenital rubella syndrome may have cataracts and many other birth defects. Photo courtesy PHIL

Having a positive rubella titer, typically defined as a IgG level of ≥10 IU/mL, means that you are immune and protected.

But what if your rubella titer is negative? What if your level is <10 IU/mL?

We know that levels of vaccine-induced rubella antibodies can decrease over time, but unlike mumps and pertussis, this does not seem lead to waning immunity with rubella.

Still, the current recommendations from the Advisory Committee on Immunization Practices (ACIP) are that:

  1. Vaccinated women of childbearing age who have received one or two doses of rubella-containing vaccine and have a rubella serum IgG levels that is not clearly positive should be administered one additional dose of MMR vaccine, with a maximum of three doses.
  2. After this additional dose, they do not need to be retested for serologic evidence of rubella immunity.
  3. Since MMR is a live vaccine, the additional dose should not be given during pregnancy or within a month of when you plan to get pregnant. You can get it while you are breastfeeding though.

How much should you be concerned about a negative rubella titer?

Although congenital rubella syndrome is not uncommon in other countries that don’t routinely vaccinate for rubella, there has not been a case of congenital rubella syndrome in the United States since – 2017.

That’s right, we have actually had two cases of congenital rubella syndrome in the US this year! In past years, these cases have all been linked to pregnant women becoming infected outside the US though, as there are thought to be very few rubella infections locally.

And two cases is a far cry from when rubella caused 2,100 neonatal deaths and 20,000 infants to be born with congenital rubella syndrome during an epidemic in the mid-1960s, before the first rubella vaccine was available.

That’s because vaccines work.

Wait, then why do some of these folks have a negative titer when they are tested?

While the easy answer is to say that they aren’t immune, it is more complicated than that. For example, some of the negative results could be false negatives (a negative test result that really should be positive). Others could possibly have low antibody levels, but they are still immune. Still, since one dose of a rubella containing vaccine is only about 97% effective, some of them could be non-responders.

Will a second or third booster dose of vaccine help increase your antibody levels? Yes, but in this situation, they will likely just rise temporarily. The second or third dose of MMR isn’t technically a booster dose, but rather a dose for those who didn’t respond to the previous doses, particularly for the measles component.

Avoiding Rubella

With a negative rubella titer, especially if you have not been previously vaccinated with one or more rubella-containing vaccines, you should likely try to avoid anyone who might have rubella.

There aren’t a lot of guidelines on how to avoid rubella though.

If you want to avoid rubella, avoid folks who aren't vaccinated against rubella.
If you want to avoid rubella, avoid folks who aren’t vaccinated against rubella. Photo courtesy of PHIL

That probably surprises you, especially with all of the information out there on how to avoid the flu, measles, mumps, and other infectious diseases, but it shouldn’t.

Symptoms of a rubella infection can include swollen lymph glands, low grade fever, a mild case of pink eye, and a red rash that can be hard to see, unless the person is overheated, like after a bath. Most importantly, people with rubella can be contagious for another few weeks, even as all of the symptoms have gone away. Also, like most viral infections, they were contagious for a few days even before they developed their first symptoms. And, believe it or not, some people with rubella might have no symptoms at all and still be contagious.

So how do you avoid someone who doesn’t even know that they are sick and are still contagious?

You basically want to try and away from anyone who might become sick and contagious…

While that sounds impossible, avoiding kids and adults who are intentionally unvaccinated, especially those who are intentionally unvaccinated and have recently traveled out of the country, can be a good start.

And like someone with a medical exemptions to getting vaccinated, if you have been vaccinated and lost your immunity to rubella, feel free to hide in the herd. This is one of the reasons everyone gets vaccinated!

What to Know About Rubella Titers

Get vaccinated and follow the latest guidelines if you are pregnant and your rubella titer is negative.

More on Rubella Titers and Immunity

Vaccines in Special Situations

Children with a cochlear implant need the Pneumovax 23 vaccine.

In addition to getting routine vaccines, there are some special situations in which kids need extra vaccines or extra dosages of vaccines.

Traveling out of the country and being pregnant are almost certainly the most common special situation when it comes to vaccines.

Vaccines for High Risk Conditions

Other special situations include children with high risk conditions, such as:

  • complement component deficiencies – MenHibrix or Menveo (infants), MenB
  • chronic heart disease – PPSV23
  • chronic lung disease (not including asthma) – PPSV23
  • diabetes mellitus – PPSV23
  • CSF leaks – PPSV23
  • cochlear implants – PPSV23
  • chronic liver disease – PPSV23
  • cigarette smoking – PPSV23
  • sickle cell disease – PPSV23
  • congenital or acquired asplenia – MenHibrix or Menveo (infants), PPSV23, MenB
  • congenital or acquired immunodeficiencies – PPSV23
  • HIV infection – PPSV23
  • chronic renal failure – PPSV23
  • nephrotic syndrome – PPSV23
  • leukemia – PPSV23
  • lymphoma – PPSV23
  • hodgkin disease – PPSV23
  • iatrogenic immunosuppression – PPSV23
  • solid organ transplant – PPSV23
  • multiple myeloma – PPSV23

In general,  the 23-valent pneumococcal polysaccharide vaccine, PPSV23 or Pneumovax 23, should be given when a high risk child is at least 2 years old and at least 4 weeks after their last dose of Prevnar 13. Some will need an additional booster dose of Pneumovax 23 after five years.

Remember, most children routinely get 4 doses of Prevnar 13 when they are 2, 4, 6, and 12-15 months old.

And while most kids just get one dose of PPSV23, others, especially those with any type of immunosuppression, get a repeat dose every five years.

Getting Revaccinated

Are there ever situations when kids need to get revaccinated?

While it might be hard to believe, there are more than a few reasons that kids get revaccinated.

The most obvious is when kids lose their vaccine records, although checking vaccine titers might help avoid repeating some or all of your child’s vaccines.

Children who have had a hematopoietic cell transplant (HCT) should routinely get revaccinated:

  • starting with inactivated vaccines six months after the transplant, including a 3-dose regiment of Prevnar 13, followed by PPSV23, a 3-dose regiment of Hib, and a yearly flu shot and other inactivated vaccines
  • continuing with a dose of MMR 24 months after the transplant if they are immunocompetent and possibly the chicken pox vaccine

Children who are adopted in a foreign country also often need to repeat all or most of their vaccines. Again, titers can often be done to avoid repeating doses.

Other Special Situations

Other special situations in which your child might need to get vaccinated off the standard immunization schedule might include:

  • missing one or more vaccines and needing to catch-up
  • getting exposed to rabies (cats, dogs, raccoons, skunks, bats, foxes, and coyotes)
  • having a wound that is not considered clean and minor (usually “wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite”) if it has been more than five years since their last dose of tetanus vaccine (or a clean and minor wound and it has been more than 10 years)
  • getting exposed to chicken pox (or shingles) or measles and not being fully vaccinated (two doses of the chicken pox and two doses of the MMR vaccines) or naturally immune, as a vaccine within 72 hours may decrease their risk of getting sick

Do your kids have a medical condition that might put them at high risk for a vaccine-preventable disease?

Do they need a vaccine that other kids don’t routinely get?

For More Information on Vaccines in Special Situations