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Dr Gaurav GuptaMAAP, MIAPAuthor of „Clippings‟ in Indian Pediatrics since 2002www.charakclinics.comSAVE – Goa, 20th April,...
Conflict of Interest Received grants from various vaccinemanufacturers including - Sanofi Pasteur - GSK - MSD - Pfize...
Scope Why do we need vaccination for Hep B? What is an ideal vaccination schedule? Quiz !
Dr. Gaurav Gupta, Charak Care Clinics, Mohali
Leading Causes of Infectious DiseaseDeaths WorldwideDiseaseLower respiratory tract infectionsDiarrheal diseasesHIV/AIDSTub...
Geographic distribution of chronic hepatitis Bvirus (HBV) infection — worldwide, 2006*
 High (>8%): 45% of global population lifetime risk of infection >60% early childhood infections common Intermediate (...
Problem statementINDIA: Falls in intermediate endemicity group HBsAg prevalence between 2% to 7%. Estimated 43-45 milli...
HBsAgHBcAgHBeAgHepatitis B Virus
Acute hepatitis B infectionAsymptomaticOrSubclinicalinfectionClinical infection-jaundice-flu like symptomFulminanthepatiti...
Chronic Hepatitis B Virus Infection Chronic viremia Responsible for most mortality Overall risk 10% 25 % of chronic HB...
0102030405060708090100Birth 1-6 mo 7-12 mo 1-4 yrs 5+ yrsAge of infectionCarrierrisk(%) Risk of Chronic HBV Carriage byAge...
Global HBV-Related Deaths By Age atAcquisition of InfectionPerinatal Period (21%)Early Childhood Period (48%)• children <5...
THE BEST PREVENTIVE METHOD ISVACCINATIONHepatitis B
Success of Hepatitis B vaccine
Mechanism of Long-Term Protectionwith Hepatitis B Vaccine18Primary vaccination seriesImmune memoryAnamnestic antibody resp...
19Serologic Response to Booster Dose ofHepatitis B Vaccine1101001000100000 6 12 18 24 30 36 42 48 54 60 66 72 78 84Age (mo...
20Long-Term Protection withHepatitis B VaccineVaccine provides long-term protectionImmunity persists despite loss of anti-...
Questions needed to be asked regarding IdealSchedule for Hep B vaccine?1. Has it been used for extensive period of time?2....
Golden Principles to Follow while choosing theSchedule for Hep B Immunization1st Dose – At birth - Prevents vertical trans...
Possible schedules for Hep BvaccinationHep B vaccine may be given in any of the following schedules:(i) Birth, 1 and 6 mon...
Importance of vaccination schedule at 0-1-6 mo/o vs 2-4-6 mo/o.Group 1Hep.B at 0-1-6Group 2Hep.B at 2-4-6Anti-HBs 10mIU/mL...
Importance of vaccination schedule at 0-1-6 mo/o vs 2-4-6 mo/o.Group 1Hep.B at 0-1-6Group 2Hep.B at 2-4-6Anti-HBs 10 mIU/m...
749.1223.44 79.706375.8684.3941.701000200030004000500060007000After 1st dose After 2nd dose After 3rd doseGMT (mIU/ml)GMT(...
GMT in infant vaccinated against Hepatitis B bydifferent vaccination schedules
Comparison of vaccination schedule indifferent countries throughout worldCountry ScheduleUSA Birth, 1-2, 6-18 mCanada Birt...
International SchedulesMajority of schedules begin at birthMost end at 6 months age or moreGap of at least 8 weeks between...
AAP recommendations• Administer Monovalent HepB to all newborns before hospital discharge• The second dose should be admin...
IAP Recommendations – ConsensusStatement 2012 IAP now recommends 0 – 6 week – 6 monthschedule for routine Hepatitis-B vac...
Rationale Closer to immunologically ideal and most widelyused 0-1-6 months schedule Confirms to latest ACIP recommendati...
Quiz – All the best !Anoushka, a 32 year mother has beentested to be HbsAg +ve during delivery.Till what (maximum) time af...
Quiz – All the best !Anoushka, a 32 year mother has beentested to be HbsAg +ve during delivery.Till what (maximum) time af...
Anoushka also wants to know if she canBreastfeed the baby?a) No, top feed onlyb) BF after completing 3 doses of vaccinec) ...
Anoushka also wants to know if she canBreastfeed the baby?a) No, top feed onlyb) BF after completing 3 doses of vaccinec) ...
When should this baby (of Anoushka) betested for Hep B disease?a) At birthb) At 3 monthsc) At 6 monthsd) At 9 months
When should this baby (of Anoushka) betested for Hep B disease?a) At birthb) At 3 monthsc) At 6 monthsd) At 9 months
How soon after taking Hep B vaccine cansomeone donate blood?a) Immediately, there is no C/Ib) 1 monthc) 3 monthsd) 6 months
How soon after taking Hep B vaccine cansomeone donate blood?a) Immediately, there is no C/Ib) 1 monthc) 3 monthsd) 6 month...
After seeing this excellent presentation youwant to know if you are really protectedagainst Hep B. What should you do?a) Y...
After seeing this excellent presentation youwant to know if you are really protectedagainst Hep B. What should you do?a) Y...
Who all should be tested for antibodiesafter Hep B vaccination?a) Everyoneb) Immunodeficient & Hemodialysis casesc) Health...
Who all should be tested for antibodiesafter Hep B vaccination?a) Everyoneb) Immunodeficient & Hemodialysis casesc) Health...
What is the protective levels of anti-HBsfor preventing Hep B disease?a) 0.1 mIU/mlb) 1 mIU/mlc) 10 mIU/mld) 100 mIU/ml
What is the protective levels of anti-HBsfor preventing Hep B disease?a) 0.1 mIU/mlb) 1 mIU/mlc) 10 mIU/mld) 100 mIU/ml
You have been tested 2 months after completinga course of Hep B vaccination, and your titresare below 10, what should be d...
You have been tested 2 months after completinga course of Hep B vaccination, and your titresare below 10, what should be d...
You (the doctor) have been tested after 2months and your titres are above 10, whenshould you be tested again? Do you needa...
You (the doctor) have been tested after 2months and your titres are above 10, whenshould you be tested again? Do you needa...
In which patients would you considerrepeated testing of anti-HBs Ab?a) In doctorsb) In patients with chronic liver disease...
In which patients would you considerrepeated testing of anti-HBs Ab?a) In doctorsb) In patients with chronic liver disease...
Your staff has accidentally put the Hep Bvaccine in the freezer compartment & itis now frozen. What should you do?a) It ha...
Your staff has accidentally put the Hep Bvaccine in the freezer compartment & itis now frozen. What should you do?a) It ha...
B/o Arti has received the first dose of Hep Bvaccine with a different doctor. You do notstock the same brand of Hep B vacc...
B/o Arti has received the first dose of Hep Bvaccine with a different doctor. You do notstock the same brand of Hep B vacc...
While doing a procedure on a patient of unknownHBsAg status, your resident Dr Nitin gets aneedlestick injury. What should ...
While doing a procedure on a patient of unknownHBsAg status, your resident Dr Nitin gets aneedlestick injury. What should ...
While doing a procedure on an HBsAg +vepatient, your resident Dr Nitin gets aneedlestick injury. What should be done?a) If...
While doing a procedure on an HBsAg +vepatient, your resident Dr Nitin gets aneedlestick injury. What should be done?a) If...
Above what age would you use Hep B /Twinrix Adult dosea) 11 yearsb) 13 yearsc) 16 yearsd) 18 years
Above what age would you use Hep B /Twinrix Adult dosea) 11 yearsb) 13 yearsc) 16 yearsd) 18 years
Bhuvan is going abroad for higher studies in1 month. He wants the Hep B vaccine.What schedule can we follow?a) There is on...
Bhuvan is going abroad for higher studies in1 month. He wants the Hep B vaccine.What schedule can we follow?a) There is on...
When would NOT vaccinate a person withHep B vaccine?a) HIV +veb) Pregnancyc) Lactationd) None of the above
When would NOT vaccinate a person withHep B vaccine?a) HIV +veb) Pregnancyc) Lactationd) None of the above
The ideal Hep B vaccination schedule is….
The ideal Hep B vaccination schedule is….0 – 1 – 6 months !
Hep b vaccine – best schedule & a quiz !
Hep b vaccine – best schedule & a quiz !
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Hep b vaccine – best schedule & a quiz !

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Hep B vaccine - Ideal Schedule.
Also quiz on Hep B vaccination

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Transcript of "Hep b vaccine – best schedule & a quiz ! "

  1. 1. Dr Gaurav GuptaMAAP, MIAPAuthor of „Clippings‟ in Indian Pediatrics since 2002www.charakclinics.comSAVE – Goa, 20th April, 2013
  2. 2. Conflict of Interest Received grants from various vaccinemanufacturers including - Sanofi Pasteur - GSK - MSD - Pfizer etc.
  3. 3. Scope Why do we need vaccination for Hep B? What is an ideal vaccination schedule? Quiz !
  4. 4. Dr. Gaurav Gupta, Charak Care Clinics, Mohali
  5. 5. Leading Causes of Infectious DiseaseDeaths WorldwideDiseaseLower respiratory tract infectionsDiarrheal diseasesHIV/AIDSTuberculosisHepatitis virusesHepatitis B virusHepatitis C virusMalariaPertussisNeonatal tetanusMeaslesEst. Deaths per Year~4.2 million~2.2 million~2.0 million~1.5 million~1 million~620,000~366,000*~900,000~295,000~213,000~197,000Source: WHO, UNICEF, Perz et al, J Hepatology, 2006
  6. 6. Geographic distribution of chronic hepatitis Bvirus (HBV) infection — worldwide, 2006*
  7. 7.  High (>8%): 45% of global population lifetime risk of infection >60% early childhood infections common Intermediate (2%-7%): 43% of global population lifetime risk of infection 20%-60% infections occur in all age groups Low (<2%): 12% of global population lifetime risk of infection <20% most infections occur in adult risk groupsGlobal Pattern of ChronicHBV Infection
  8. 8. Problem statementINDIA: Falls in intermediate endemicity group HBsAg prevalence between 2% to 7%. Estimated 43-45 million cases per year. 40 million carriers. 100,000 death annually by disease related toHBV infection. Of 25 million newborn annually, 1 millionruns lifetime risk of HBV infection
  9. 9. HBsAgHBcAgHBeAgHepatitis B Virus
  10. 10. Acute hepatitis B infectionAsymptomaticOrSubclinicalinfectionClinical infection-jaundice-flu like symptomFulminanthepatitisDeathChronicCarrierRecoveryOrImmunityMinimalliverDiseaseChronicHepatitisPrimaryhepatocellularcarcinomacirrhosisDEATH
  11. 11. Chronic Hepatitis B Virus Infection Chronic viremia Responsible for most mortality Overall risk 10% 25 % of chronic HBV patients will diedue to liver disease Higher risk with early infection
  12. 12. 0102030405060708090100Birth 1-6 mo 7-12 mo 1-4 yrs 5+ yrsAge of infectionCarrierrisk(%) Risk of Chronic HBV Carriage byAge of Infection
  13. 13. Global HBV-Related Deaths By Age atAcquisition of InfectionPerinatal Period (21%)Early Childhood Period (48%)• children <5Late Period (31%)• children >5• adolescents• adults
  14. 14. THE BEST PREVENTIVE METHOD ISVACCINATIONHepatitis B
  15. 15. Success of Hepatitis B vaccine
  16. 16. Mechanism of Long-Term Protectionwith Hepatitis B Vaccine18Primary vaccination seriesImmune memoryAnamnestic antibody responseRapid rise in anti-HBsProtection from infectionExposureto HBV
  17. 17. 19Serologic Response to Booster Dose ofHepatitis B Vaccine1101001000100000 6 12 18 24 30 36 42 48 54 60 66 72 78 84Age (months)GMTAnti-HBs(mIU/ml)PrimaryseriesBooster dose (simulatingnatural infection)Source: Williams and Goldstein, CDC2 weeks post-booster4 weeks post-booster1 yearpost-booster
  18. 18. 20Long-Term Protection withHepatitis B VaccineVaccine provides long-term protectionImmunity persists despite loss of anti-HBsdocumented protection up to 15 years lifelong protection likelycontinued follow-up needed to determine durationof protectionBooster doses of hepatitis B vaccine NOTcurrently recommended
  19. 19. Questions needed to be asked regarding IdealSchedule for Hep B vaccine?1. Has it been used for extensive period of time?2. Does it protect the highest “at risk” population?3. Are there enough evidence regarding itseffectiveness?4. Are other countries using the same in their NationalSchedules?5. Can it be piggy-backed on our National Schedule?
  20. 20. Golden Principles to Follow while choosing theSchedule for Hep B Immunization1st Dose – At birth - Prevents vertical transmission2nd Dose – 4 wk later – Limited seroconversion after 1stdose, hence closely spaced second dose – preventsimmediate horizontal transmission3rd Dose -- Min 8 weeks after 2nd Dose,-- Min 16 weeks after 1st Dose,-- After 24 weeks age,(ACIP/ AAP recommendations)Increased gap between 2nd & 3rd dose increases Ab titres
  21. 21. Possible schedules for Hep BvaccinationHep B vaccine may be given in any of the following schedules:(i) Birth, 1 and 6 months(ii) Birth, 6 and 14 weeks(iii) 6, 10 and 14 weeks(iv) Birth, 6 weeks, 6 months(v) Birth, 6 weeks,10 weeks, 14 weeksThe IDEAL schedule is 0 1 6 months.
  22. 22. Importance of vaccination schedule at 0-1-6 mo/o vs 2-4-6 mo/o.Group 1Hep.B at 0-1-6Group 2Hep.B at 2-4-6Anti-HBs 10mIU/mL47% 9%Greenberg D et al.- Ped. Inf. Dis. Journal. 21(8):769-776, August 2002Results: Anti-HBs Post-dose 2
  23. 23. Importance of vaccination schedule at 0-1-6 mo/o vs 2-4-6 mo/o.Group 1Hep.B at 0-1-6Group 2Hep.B at 2-4-6Anti-HBs 10 mIU/mL100%[97.2 ; 100]99.0%[94.3 ; 99.4]GMTs3 643 mIU/mL[502;709]1 052 mIU/mL[163;253]Greenberg D et al.- Ped. Inf. Dis. Journal. 21(8):769-776, August 2002Results: Anti-HBs Post-dose 3
  24. 24. 749.1223.44 79.706375.8684.3941.701000200030004000500060007000After 1st dose After 2nd dose After 3rd doseGMT (mIU/ml)GMT(mIU/ml)GMT (mIU/ml) 0,1,2 scheduleGMT (mIU/ml) 0,1,6 scheduleAb titres (ShanvacB) with 0-1-2 & 0-1-6schedules
  25. 25. GMT in infant vaccinated against Hepatitis B bydifferent vaccination schedules
  26. 26. Comparison of vaccination schedule indifferent countries throughout worldCountry ScheduleUSA Birth, 1-2, 6-18 mCanada Birth, 1, 6mEngland Birth, 1, 2, 6Germany 2,4, 11-14 mSouth Africa 6,10,14 weeksAustralia 0, 2, 4, 6mChina Birth, 1, 6mIndia Birth, 6,10,14 weeks
  27. 27. International SchedulesMajority of schedules begin at birthMost end at 6 months age or moreGap of at least 8 weeks between 2nd and 3rd dosesIf the gap is less, then a 4th dose givenMajority have monovalent Hep B vaccine
  28. 28. AAP recommendations• Administer Monovalent HepB to all newborns before hospital discharge• The second dose should be administered at age of 1 to 2 months• The final dose should be administered no earlier than age 24 weeks
  29. 29. IAP Recommendations – ConsensusStatement 2012 IAP now recommends 0 – 6 week – 6 monthschedule for routine Hepatitis-B vaccination inoffice practice for children: the first dose at birth second dose at 6 weeks and third dose at 6 months Administering Birth dose to all infants beforehospital discharge critical Final dose not to be administered before 6m ofage
  30. 30. Rationale Closer to immunologically ideal and most widelyused 0-1-6 months schedule Confirms to latest ACIP recommendations whereinthe final dose of Hep B vaccine is administered noearlier than age 24 weeks and at least 16 weeksafter the first dose. 0-1-6 is the schedule widely followed across theworld and for which there is abundant evidence ofeffectiveness (Taiwan, Thailand and USA) The classic 0, 1, and 6 months schedule yields ahigh seroconversion rates and higher titers of anti-HBs that will persist for an extended period oftime.
  31. 31. Quiz – All the best !Anoushka, a 32 year mother has beentested to be HbsAg +ve during delivery.Till what (maximum) time after birthwould you recommend HBIGadministration?a) Within 12 hours onlyb) Within 24 hoursc) Within 48 hoursd) Within 7 days
  32. 32. Quiz – All the best !Anoushka, a 32 year mother has beentested to be HbsAg +ve during delivery.Till what (maximum) time after birthwould you recommend HBIGadministration?a) Within 12 hours onlyb) Within 24 hoursc) Within 48 hoursd) Within 7 days
  33. 33. Anoushka also wants to know if she canBreastfeed the baby?a) No, top feed onlyb) BF after completing 3 doses of vaccinec) BF from birthd) BF only if received HBIG
  34. 34. Anoushka also wants to know if she canBreastfeed the baby?a) No, top feed onlyb) BF after completing 3 doses of vaccinec) BF from birthd) BF only if received HBIG
  35. 35. When should this baby (of Anoushka) betested for Hep B disease?a) At birthb) At 3 monthsc) At 6 monthsd) At 9 months
  36. 36. When should this baby (of Anoushka) betested for Hep B disease?a) At birthb) At 3 monthsc) At 6 monthsd) At 9 months
  37. 37. How soon after taking Hep B vaccine cansomeone donate blood?a) Immediately, there is no C/Ib) 1 monthc) 3 monthsd) 6 months
  38. 38. How soon after taking Hep B vaccine cansomeone donate blood?a) Immediately, there is no C/Ib) 1 monthc) 3 monthsd) 6 months(Similarly draw blood for testing beforevaccination with Hep B vaccine)
  39. 39. After seeing this excellent presentation youwant to know if you are really protectedagainst Hep B. What should you do?a) You have taken 3 doses, you areobviously protectedb) Do an anti-HBs immediately.c) Do an HBsAg immediatelyd) You need to take 1 dose & then test foranti-HBse) You need to take all 3 doses again & thentest for anti-HBs
  40. 40. After seeing this excellent presentation youwant to know if you are really protectedagainst Hep B. What should you do?a) You have taken 3 doses, you areobviously protectedb) Do an anti-HBs immediately.c) Do an HBsAg immediatelyd) You need to take 1 dose & then test foranti-HBse) You need to take all 3 doses again & thentest for anti-HBs
  41. 41. Who all should be tested for antibodiesafter Hep B vaccination?a) Everyoneb) Immunodeficient & Hemodialysis casesc) Health care workers dealing with blood& blood productsd) Infants of HBsAg +ve mothere) Family members of HBsAg +ve person
  42. 42. Who all should be tested for antibodiesafter Hep B vaccination?a) Everyoneb) Immunodeficient & Hemodialysis casesc) Health care workers dealing with blood& blood productsd) Infants of HBsAg +ve mothere) Family members of HBsAg +ve person
  43. 43. What is the protective levels of anti-HBsfor preventing Hep B disease?a) 0.1 mIU/mlb) 1 mIU/mlc) 10 mIU/mld) 100 mIU/ml
  44. 44. What is the protective levels of anti-HBsfor preventing Hep B disease?a) 0.1 mIU/mlb) 1 mIU/mlc) 10 mIU/mld) 100 mIU/ml
  45. 45. You have been tested 2 months after completinga course of Hep B vaccination, and your titresare below 10, what should be done?a) Nothing can be done, you will remainsusceptibleb) Do an HBsAg t/r/o HBV infectionc) Repeat another course, and if your titresremain low, then you will be susceptibled) If the second course fails, try ID Hep BVaccinee) If the second course fails, try a course ofdouble dose Twinrix
  46. 46. You have been tested 2 months after completinga course of Hep B vaccination, and your titresare below 10, what should be done?a) Nothing can be done, you will remainsusceptibleb) Do an HBsAg t/r/o HBV infectionc) Repeat another course, and if your titresremain low, then you will be susceptibled) If the second course fails, try ID Hep BVaccinee) If the second course fails, try a course ofdouble dose Twinrix
  47. 47. You (the doctor) have been tested after 2months and your titres are above 10, whenshould you be tested again? Do you needa booster as a HCW?a) No need for tests & no booster – you areprotected for lifeb) Tested every year, booster if level below10c) Tested every 5 years, booster as aboved) Tested every 10 years, booster as above
  48. 48. You (the doctor) have been tested after 2months and your titres are above 10, whenshould you be tested again? Do you needa booster as a HCW?a) No need for tests & no booster – you areprotected for lifeb) Tested every year, booster if level below10c) Tested every 5 years, booster as aboved) Tested every 10 years, booster as above
  49. 49. In which patients would you considerrepeated testing of anti-HBs Ab?a) In doctorsb) In patients with chronic liver diseasec) In patients of CRFd) In HIV +ve & immunocompromisedchildren
  50. 50. In which patients would you considerrepeated testing of anti-HBs Ab?a) In doctorsb) In patients with chronic liver diseasec) In patients of CRFd) In HIV +ve & immunocompromisedchildren
  51. 51. Your staff has accidentally put the Hep Bvaccine in the freezer compartment & itis now frozen. What should you do?a) It has to be discardedb) Thaw it gently and reuse once it iscompletely liquid againc) Use it as a combination vaccine withDPT + Hib
  52. 52. Your staff has accidentally put the Hep Bvaccine in the freezer compartment & itis now frozen. What should you do?a) It has to be discardedb) Thaw it gently and reuse once it iscompletely liquid againc) Use it as a combination vaccine withDPT + Hib
  53. 53. B/o Arti has received the first dose of Hep Bvaccine with a different doctor. You do notstock the same brand of Hep B vaccine.What should you do?a) Ask her to go back to the same doctorb) Buy the same brand and give to the childby calling it again after a few daysc) Use whatever brand is available with you
  54. 54. B/o Arti has received the first dose of Hep Bvaccine with a different doctor. You do notstock the same brand of Hep B vaccine.What should you do?a) Ask her to go back to the same doctorb) Buy the same brand and give to the childby calling it again after a few daysc) Use whatever brand is available with you
  55. 55. While doing a procedure on a patient of unknownHBsAg status, your resident Dr Nitin gets aneedlestick injury. What should be done?a) If he is documented fully immunized – nothingb) Documented fully immunized – 1 dose of HepB vaccinec) Unvaccinated / partially vaccinated –Hep Bvaccine as per schedule immediatelyd) Unvaccinated/ partially vaccinated – Hep Bvaccine + HBIG immediately
  56. 56. While doing a procedure on a patient of unknownHBsAg status, your resident Dr Nitin gets aneedlestick injury. What should be done?a) If he is documented fully immunized – nothingb) Documented fully immunized – 1 dose of HepB vaccinec) Unvaccinated / partially vaccinated –Hep Bvaccine as per schedule immediatelyd) Unvaccinated/ partially vaccinated – Hep Bvaccine + HBIG immediately
  57. 57. While doing a procedure on an HBsAg +vepatient, your resident Dr Nitin gets aneedlestick injury. What should be done?a) If he is documented fully immunized withpost vaccination testing – nothingb) If he is documented fully immunized butwithout post vaccination testing – Singledose of vaccinec) Unvaccinated / partially vaccinated –HBIG & Hep B vaccine
  58. 58. While doing a procedure on an HBsAg +vepatient, your resident Dr Nitin gets aneedlestick injury. What should be done?a) If he is documented fully immunized withpost vaccination testing – nothingb) If he is documented fully immunized butwithout post vaccination testing – Singledose of vaccinec) Unvaccinated / partially vaccinated –HBIG & Hep B vaccine
  59. 59. Above what age would you use Hep B /Twinrix Adult dosea) 11 yearsb) 13 yearsc) 16 yearsd) 18 years
  60. 60. Above what age would you use Hep B /Twinrix Adult dosea) 11 yearsb) 13 yearsc) 16 yearsd) 18 years
  61. 61. Bhuvan is going abroad for higher studies in1 month. He wants the Hep B vaccine.What schedule can we follow?a) There is only 1 recommended schedulefor adults 0,1 & 6 monthsb) Accelerated schedule 0, 7, 21 days andthen booster after 1 yearc) Accelerated Schedule 0, 1, 2 month andbooster after 1 year
  62. 62. Bhuvan is going abroad for higher studies in1 month. He wants the Hep B vaccine.What schedule can we follow?a) There is only 1 recommended schedulefor adults 0,1 & 6 monthsb) Accelerated schedule 0, 7, 21 days andthen booster after 1 yearc) Accelerated Schedule 0, 1, 2 month andbooster after 1 year
  63. 63. When would NOT vaccinate a person withHep B vaccine?a) HIV +veb) Pregnancyc) Lactationd) None of the above
  64. 64. When would NOT vaccinate a person withHep B vaccine?a) HIV +veb) Pregnancyc) Lactationd) None of the above
  65. 65. The ideal Hep B vaccination schedule is….
  66. 66. The ideal Hep B vaccination schedule is….0 – 1 – 6 months !
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