7.6.1.1: Disease Recognition and Control of Hepatitis B Virus (HBV) Infection

Facilities should have written policies for inclusion and exclusion of children known to be infected with hepatitis B virus (HBV) and for immunization of all children with hepatitis B vaccine per the “Recommended Immunization Schedules” for children and adolescents. All infants should complete a three dose series of hepatitis B vaccine beginning at birth as recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) (1). When a child who is an HBV carrier is admitted to a facility, the facility director and primary caregivers/teachers should be informed.

Children who carry HBV chronically and who have no behavioral or medical risk factors, such as aggressive behavior (such as biting or frequent scratching), generalized dermatitis (weeping skin lesions), or bleeding problems, may be admitted to the facility without restrictions.

Testing of children for HBV should not be a prerequisite for admission to facilities.

With regard to infection control measures and handling of blood or blood-containing body fluids, every person should be assumed to be an HBV carrier with regard to blood exposure. All blood should be considered as potentially containing HBV. Child care personnel should adopt Standard Precautions, as outlined in Prevention of Exposure to Blood and Body Fluids, Standard 3.2.3.4.

Toys and objects that young children (infants and toddlers) mouth should be cleaned and sanitized, as stated in Standards 3.3.0.2-3.3.0.3.

Toothbrushes and pacifiers should be individually labeled so that the children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2.

RATIONALE

Prior to routine hepatitis B immunization of infants, transmission in child care facilities was reported (2,3). Currently the risk of transmitting the disease in child care is theoretically small because of the low risk of transmission, implementation of infection control measures, and high immunization rates. Immunization not only will reduce the potential for transmission but also will allay anxiety about transmission from children and staff in the child care setting who may be carriers of hepatitis B (1). However, children who are HBV carriers (particularly children born in countries highly endemic for HBV) could be enrolled in child care. Thus, transmission of HBV in the child care setting is of concern to public health authorities.

The risk of disease transmission from an HBV-carrier child or staff member with no behavioral risk factors and without generalized dermatitis or bleeding problems is considered rare. This extremely low risk does not justify exclusion of an HBV-carrier child from out-of-home care, nor does it justify the routine screening of children as possible HBV carriers prior to admission to child care.

HBV transmission in a child care setting is most likely to occur through direct exposure via bites or scratches that break the skin and introduce blood or body secretions from the HBV carrier into a susceptible person. Indirect transmission via blood or saliva through environmental contamination may be possible but has not been documented. Saliva contains much less virus (1/1000) than blood; therefore, the potential infection from saliva is much lower than that of blood.

No data are available to indicate the risk of transmission if a susceptible person bites an HBV carrier. When the HBV statuses of both the biting child and the victim are unknown, the risk of HBV transmission would be extremely low because of the expected low incidence of HBV carriage by children of preschool-age and the low efficiency of disease transmission by bite exposure. Because a bite in this situation is extremely unlikely to involve an HBV-carrier child, screening is not warranted, particularly in children who are immunized appropriately against HBV (1), but each situation should be evaluated individually. In the rare circumstance that an unimmunized child bites a known HBV carrier, the hepatitis B vaccine series should be initiated (4).

COMMENTS

Parents/guardians are not required to share information about their child’s HBV status, but they should be encouraged to do so. For additional information regarding HBV consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children

REFERENCES

1. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.
2. Deseda, D. D., C. N. Shapiro, K. Carroll. 1994. Hepatitis B virus transmission between a child and staff member at a day-care center. Pediatr Infect Dis J 13:828-30.
3. Shapiro, C. N., L. F. McCaig, K. F. Genesheimer, et al. 1989. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 8:870-75.
4. Shane, A. L., L. K. Pickering. 2008. Infections associated with group child care. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.