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Route of transmission for hepatitis b. Hepatitis B: Comprehensive Facts, Statistics, and Guidelines

What is hepatitis B? What are the risk factors for hepatitis B infection? How is hepatitis B transmitted? Get answers to these and other key questions about hepatitis B.

Hepatitis B Vaccination Guidelines for Adults

The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B vaccination for the following groups of adults:

  • All infants
  • Unvaccinated children aged <19 years
  • Adults aged 19 through 59 years
  • Adults aged 60 years and older with risk factors for hepatitis B

The following groups may also receive hepatitis B vaccination:

  • Adults aged 60 years and older without known risk factors for hepatitis B
  • Persons at risk for infection by sexual exposure, such as sex partners of persons who test positive for hepatitis B surface antigen (HBsAg), sexually active persons who are not in a long-term, mutually monogamous relationship, and persons seeking evaluation or treatment for a sexually transmitted infection
  • Persons at risk for infection by percutaneous or mucosal exposure to blood, such as persons with current or recent injection use, household contacts of persons who test positive for HBsAg, residents and staff of facilities for persons with developmental disabilities, health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids, and persons on maintenance dialysis
  • Others, such as international travelers to countries with high or intermediate levels of endemic hepatitis B virus (HBV) infection, persons with hepatitis C virus infection, persons with chronic liver disease, persons with HIV infection, and incarcerated persons

Implementing Hepatitis B Vaccination Guidelines

To ensure vaccination of persons at risk for HBV infection, health care providers should:

  1. Offer HepB vaccination to all adults aged 19–59 years who have not previously completed vaccination, as well as adults > 60 years with risk factors for hepatitis B or without identified risk factors but seeking protection.
  2. Implement standing orders to administer HepB vaccine as part of routine services to adults who have not completed the vaccine series.
  3. Offer HepB vaccination, when feasible, in outreach and other settings in which services are provided to persons at risk for HBV infection (e.g., syringe services programs, HIV testing sites, HIV prevention programs, homeless shelters).

Interpreting Hepatitis B Serologic Test Results

Hepatitis B serologic testing involves measurement of several hepatitis B virus (HBV)-specific antigens and antibodies. Different serologic “markers” or combinations of markers are used to identify different phases of HBV infection and to determine whether a patient has acute or chronic HBV infection, is immune to HBV as a result of prior infection or vaccination, or is susceptible to infection.

Test and ResultInterpretationAction
HBsAg—PositiveTotal anti-HBc — PositiveIgM anti-HBc — PositiveAnti-HBs — NegativeAcute infectionLink to hepatitis B care
HBsAg — PositiveTotal anti-HBc — PositiveIgM anti-HBc — Negative1Anti-HBs — NegativeChronic InfectionLink to hepatitis B care
HBsAg — NegativeTotal anti-HBc — PositiveAnti-HBs — PositiveResolved InfectionCounsel about HBV infection reactivation risk
HBsAg — NegativeTotal anti-HBc — NegativeAnti-HBs — Positive2Immune from receipt of prior vaccination (if documented complete series)If no documentation of full vaccination, then complete vaccine series per ACIP recommendations.
HBsAg — NegativeTotal anti-HBc — PositiveAnti-HBs — NegativeOnly core antibody is positive. See possible interpretations and corresponding actions:Resolved infection where anti-HBs levels have waned, Occult Infection, Passive transfer of anti-HBc to an infant born to an HBsAg-positive gestational parent, A false positive, thus patient is susceptible, A mutant HBsAg strain that is not detectable by laboratory assay
HBsAg — NegativeTotal anti-HBc — NegativeAnti-HBs — Negative3Susceptible, never infected (if no documentation of HepB vaccine series completion)Offer HepB vaccine per ACIP recommendations

Notes:

  1. IgM anti-HBc also might be positive in persons with chronic infection during severe HBV infection flares or reactivation.
  2. Immune if anti-HBs concentration is >10 mIU/mL after vaccine series.
  3. Susceptible if no documentation of HepB vaccine series completion.

Hepatitis B Transmission Routes

Hepatitis B is primarily transmitted through the following routes:

  • Unprotected sexual contact with an infected person
  • Sharing of needles, syringes, or other equipment to inject drugs
  • Exposure to infected blood or body fluids, such as through needle sticks or other sharps injuries in healthcare settings
  • From an infected mother to her baby during childbirth

Hepatitis B is not spread through breastfeeding, food or water, or by casual contact such as hugging, kissing, or sharing eating utensils or drinks.

Hepatitis B Prevalence and Burden

Hepatitis B is a leading cause of liver disease worldwide. According to the World Health Organization (WHO):

  • Approximately 296 million people were living with chronic hepatitis B infection in 2019.
  • In 2019, hepatitis B resulted in an estimated 1.5 million new infections and 820,000 deaths, mostly from cirrhosis and liver cancer.
  • The global prevalence of chronic hepatitis B infection is approximately 3.9%.
  • The burden of hepatitis B is highest in the WHO Western Pacific and African regions, where prevalence can exceed 6% in some countries.

Hepatitis B Prevention and Control Strategies

Key strategies for preventing and controlling hepatitis B include:

  1. Universal hepatitis B vaccination, including for all infants and high-risk groups
  2. Timely diagnosis and linkage to care for those with chronic hepatitis B infection
  3. Appropriate management and treatment of chronic hepatitis B to reduce the risk of liver disease progression and transmission
  4. Harm reduction interventions, such as needle and syringe programs, to prevent transmission among people who inject drugs
  5. Screening of pregnant women and treatment to prevent mother-to-child transmission
  6. Infection control practices in healthcare settings to prevent transmission

Hepatitis B Research and Innovations

Ongoing research and innovations in hepatitis B include:

  • Development of new antiviral drugs and therapy combinations to improve treatment outcomes
  • Exploration of therapeutic vaccines and gene therapies to achieve a functional cure for chronic hepatitis B
  • Improvements in diagnostic tools, including point-of-care tests, to expand access to testing
  • Implementation research to optimize the delivery of hepatitis B services, particularly in resource-limited settings

Hepatitis B – Vaccination of Adults

Adults recommended to receive HepB vaccine:

The Advisory Committee on Immunization Practices (ACIP) recommends that the following people should receive hepatitis B vaccination:

  • All infants
  • Unvaccinated children aged <19 years
  • Adults aged 19 through 59 years
  • Adults aged 60 years and older with risk factors for hepatitis B

The following groups may receive hepatitis B vaccination:

  • Adults aged 60 years and older without known risk factors for hepatitis B

Risk factors for hepatitis B

  • Persons at risk for infection by sexual exposure
    • Sex partners of persons who test positive for hepatitis B surface antigen (HBsAg)
    • Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months)
    • Persons seeking evaluation or treatment for a sexually transmitted infection
    • Men who have sex with men
  • Persons at risk for infection by percutaneous or mucosal exposure to blood
    • Persons with current or recent injection use
    • Household contacts of persons who test positive for HBsAg
    • Residents and staff of facilities for persons with developmental disabilities
    • Health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids
    • Persons on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis, and persons who are predialysis
    • Persons with diabetes at the discretion of the treating clinician
  • Others
    • International travelers to countries with high or intermediate levels of endemic hepatitis B virus (HBV) infection (HBsAg prevalence of ≥2%)
    • Persons with hepatitis C virus infection
    • Persons with chronic liver disease (including, but not limited to, persons with cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or an alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
    • Persons with HIV infection
    • Incarcerated persons

Implementation Guidelines

To ensure vaccination of persons at risk for HBV infection, health care providers should:

  • Offer HepB vaccination to all adults aged 19–59 years who have not previously completed vaccination, as well as adults > 60 years with risk factors for hepatitis B or without identified risk factors but seeking protection.
  • Implement standing orders to administer HepB vaccine as part of routine services to adults who have not completed the vaccine series.
  • Offer HepB vaccination, when feasible, in outreach and other settings in which services are provided to persons at risk for HBV infection (e.g., syringe services programs, HIV testing sites, HIV prevention programs, homeless shelters).

Interpretation of Hepatitis B Serologic Test Results

Hepatitis B serologic testing involves measurement of several hepatitis B virus (HBV)-specific antigens and antibodies. Different serologic “markers” or combinations of markers are used to identify different phases of HBV infection and to determine whether a patient has acute or chronic HBV infection, is immune to HBV as a result of prior infection or vaccination, or is susceptible to infection.

Test and ResultInterpretationAction
HBsAg—Positive
Total anti-HBc — Positive
IgM anti-HBc — Positive
Anti-HBs — Negative
Acute infectionLink to hepatitis B care
HBsAg — Positive
Total anti-HBc — Positive
IgM anti-HBc — Negative1
Anti-HBs — Negative
Chronic InfectionLink to hepatitis B care
HBsAg — Negative
Total anti-HBc — Positive
Anti-HBs — Positive
Resolved InfectionCounsel about HBV infection reactivation risk
HBsAg — Negative
Total anti-HBc — Negative
Anti-HBs — Positive2
Immune from receipt of prior vaccination (if documented complete series)If no documentation of full vaccination, then complete vaccine series per ACIP recommendations.
HBsAg — Negative
Total anti-HBc — Positive
Anti-HBs — Negative
Only core antibody is positive. See possible interpretations and corresponding actions:
Resolved infection where anti-HBs levels have wanedCounsel about HBV infection reactivation risk
Occult InfectionLink to hepatitis B care
Passive transfer of anti-HBc to an infant born to an HBsAg-positive gestational parentNo action
A false positive, thus patient is susceptibleOffer HepB vaccine per Advisory Committee on Immunization Practices (ACIP)
A mutant HBsAg strain that is not detectable by laboratory assayLink to hepatitis B care
HBsAg — Negative
Total anti-HBc — Negative
Anti-HBs — Negative3
Susceptible, never infected (if no documentation of HepB vaccine series completion)Offer HepB vaccine per ACIP recommendations

1 IgM anti-HBc also might be positive in persons with chronic infection during severe HBV infection flares or reactivation.

2 Immune if anti-HBs concentration is >10 mIU/mL after vaccine series completion.

3 Anti-HBs concentrations might wane over time among vaccine responders. People with a documented, complete HepB vaccine series typically do not need to be revaccinated, except for special populations like patients on hemodialysis or health care personnel.

Ways of transmission of hepatitis

When you first find out that you have hepatitis, one of the first questions you have is how and where could I get infected? How can I live now, behave with my loved ones, so as not to infect them? Let’s try to figure it out. Find out how contagious hepatitis is, how you could get infected, and how dangerous you are to others.

The hepatitis B virus is highly contagious. This is due to the colossal amount of hepatitis B virus particles contained in 1 ml of blood. In addition, the hepatitis B virus can remain on surfaces (for example, personal items) for several days.

The hepatitis B virus is found in the blood and body fluids of a sick person. Infection occurs when one’s blood, saliva, semen, or vaginal discharge enter the bloodstream or onto damaged skin and mucous membranes of another person.

These are the circumstances under which this happens:

  • Intravenous drugs

    This is one of the most common causes. Up to 75% of people who use drugs, or have practiced it in the past, are infected with hepatitis B. And sometimes one injection is enough. The risk of infection increases with repeated intravenous drug use. At the tip of the needle, about 1,000,000 viral particles can fit; when you try to wash the needle, even with special solutions, you most likely will not be able to completely remove them.

    Hepatitis B infection has been reported by inhaling cocaine through the nose. The vessels of the nasal mucosa are damaged when the drug is inhaled, this is especially true for chronic use, so this route of transmission of the virus is also possible.

  • Sexual contact

    People who do not use barrier contraception, have multiple sex partners, and have homosexual sex are at greater risk. Using condoms reduces the risk of infection, but it may not be enough. It is essential that the sexual partner is vaccinated.

  • Transmission of the virus to the child during childbirth

    The risk of infection of the child – at the time of delivery, when there may be contact between the blood of mother and child. In the first hours of life, a child is given a vaccine that protects him from infection.

    Hepatitis B virus can be in the milk of a nursing mother, but the baby’s digestive juices and enzymes prevent infection. In addition, the child will already be vaccinated. Thus, a woman with hepatitis B can breastfeed a vaccinated baby.

  • Traveling and living in countries with a high incidence of hepatitis B

    There are some countries where hepatitis B is particularly common. These are South Africa, Amazonia, most of Asia, the Middle East, the northern territories of Eastern and Central Europe, and India. And these countries often lack a national hepatitis B vaccination program. Most people in these countries are infected with the hepatitis B virus at birth or in early childhood.

  • Transfusion of blood and its components

    Mandatory testing of donors for hepatitis B has existed for a long time, but, nevertheless, the risk of infection during the transfusion of blood and its components still exists. This also applies to patients with hemophilia, as they may require plasma transfusions.

  • Tattoos and piercings

    These manipulations are associated with damage to the skin, often with minor bleeding. The risk of infection arises if non-sterile instruments are used.

  • Household contacts

    This refers to household contacts of those who live closely in one area, for example, in a family, a hostel, in a prison. Although in this case the risk is much less than with sexual intercourse, it is still there. It is important to avoid the use of common sharp and injuring objects: nail scissors, razors, toothbrushes. All people living in close household contact with patients with hepatitis B are recommended to be vaccinated.

  • If you have hepatitis B, inform your sexual partners, family members, they should all be vaccinated against hepatitis B. Use barrier contraception, use only personal hygiene items.

    Even after reading the information about the ways of transmission of the virus, you may still have questions, especially about your loved ones, your behavior towards them. Here are the most frequently asked questions:

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    Hepatitis B – what is the disease, how is it transmitted, symptoms and treatment

    Hepatitis B virus

    The causative agent of hepatitis B (hepatitis b) is a DNA-containing virus from the family Hepadnaviridae (hepadnaviruses) of the genus Orthohepadnavirus.

    Structure of hepatitis B virus

    The core of the virus contains its genetic material (DNA) and the enzyme DNA polymerase, and the outer and inner shells contain special antigen proteins. Each of them has its own role in the life cycle of the virus.

    So, surface antigen or HBsAg (hepatitis B surface antigen), which is embedded in the outer shell, is responsible for the introduction of the virus into liver cells.

    The hepatitis B surface antigen (HBsAg) is also called Australian because it was first detected in the blood of Australian Aborigines.

    Nuclear antigen , or HBcAg (hepatitis B core antigen), located in the inner shell of the virus, is highly immunogenic (causes the body’s immune response to the virus).

    Infectivity antigen , or HBeAg (hepatitis B e antigen), which is a transformed nuclear antigen and is also located in the inner envelope of the virus, is responsible for the reproduction of the virus in the cells of the body.

    The hepatitis B virus is insensitive to ultraviolet radiation and is very stable in the external environment: it is viable at room temperature for 3 months, when frozen – 15-20 years, when heated to 60 ° C – 4 hours. In addition, a very small amount of this pathogen is enough to cause infection. Therefore, the hepatitis B virus poses a serious threat.

    Routes of transmission

    Hepatitis B virus – bloodborne infection . This means that the pathogen is transmitted by contact with the blood, as well as other biological fluids of the infected person (saliva, ejaculate and urine). However, blood is the most contagious.

    Hepatitis B virus is most commonly transmitted through contact with infected blood

    Potentially hazardous situations:

    • medical procedures: hemodialysis, blood transfusion, dental treatment;
    • cosmetic operations: piercing, tattooing; shaving, manicure, brushing teeth with someone else’s toothbrush;
    • sharing a syringe for intravenous administration of narcotic substances;
    • unprotected sex.

    Hepatitis B is included in the list of sexually transmitted infections: infection is possible through the smallest lesions in the vagina, on the penis or in the anus.

    Another common route of infection is infection of the child from the mother during childbirth. For example, in countries in Africa and Southeast Asia, where viral hepatitis B is widespread, most patients contracted it from an infected mother.

    Specificity of the immune response to hepatitis B virus

    After entering the human body, the virus is delivered to the liver through the bloodstream, causing an immunopathological reaction. This means that it is not the hepatitis B virus itself that destroys liver cells, but special substances (cytotoxic T-cells) that the immune system produces. It turns out that the body can stop the attack of the hepatitis B virus only at the cost of destroying its own cells – liver cells infected with the virus.

    There is a relationship between the severity of the immune response and the outcome of the disease. With an adequate immune response, the course of the disease is often severe due to the death of infected cells in large numbers, but later complete recovery occurs and acute hepatitis B does not turn into chronic. And with erased and mild forms of the disease, when a certain amount of the virus remains in the liver cells, the likelihood of developing chronic hepatitis B is much higher.

    According to some reports, even for those people who have been ill with the production of antibodies, there is still a risk that the infection will reactivate. This is possible, for example, in immunodeficiency states due to oncological diseases, HIV infection, etc.

    Acute and chronic hepatitis B. Symptoms of acute hepatitis B

    There are several periods in the development of viral hepatitis B:

    • setter,
    • preicteric,
    • icteric.

    The incubation period for hepatitis B infection can be several months (30 to 180 days, average 75 to 80 days). At this time, the patient, as a rule, does not know about his illness, but is already contagious to others.

    The infectiousness of a person with viral hepatitis B can be judged by the results of blood tests.

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    If the test detects the HBeAg viral antigen in the biomaterial, this means that the virus is actively multiplying in the body and such a patient can infect other people. When HBeAg is no longer detected in the blood, and anti-HBe antibodies appear instead, the patient is no longer contagious.

    In the preicteric period, the disease may masquerade as other diseases.

    Symptoms of the preicteric period of the disease:

    • weakness,
    • fever,
    • joint pain,
    • nausea, vomiting and diarrhea,
    • allergic rashes.

    A period of jaundice is usually accompanied by the following symptoms:

    • yellowing of the skin and/or whites of the eyes,
    • severe weakness,
    • decreased appetite,
    • dizziness and headache,
    • increased pruritus.

    The duration of this period is from several days to several months, on average 2-6 weeks. The signs of hepatitis B are the same in men and women. Sometimes in patients with viral hepatitis B, the disease proceeds without jaundice.

    Jaundice is one of the symptoms of hepatitis B

    If the body coped with inflammation and viral load, infection ends with recovery. In adults, this happens in 90-95% of cases.

    If the immunity of an infected person could not overcome the virus, chronic hepatitis B develops. Most often this occurs in children. Thus, hepatitis B becomes chronic in about 95% of those infected in infancy and early childhood, and only in 5% of adults.

    Hepatitis B virus is one of the most common causes of chronic liver diseases.

    Possible complications of hepatitis B

    Acute hepatitis B can lead to a number of complications:

    • acute liver failure;
    • massive hemorrhagic syndrome (tendency to bleeding).

    If hepatitis B becomes chronic, it can cause life-threatening complications:

    • cirrhosis of the liver – replacement of healthy organ tissue with connective tissue;
    • hepatocellular carcinoma – primary liver cancer.

    In order to timely detect the disease, and in the chronic form of hepatitis B, to control the risk of developing dangerous complications, laboratory diagnostic methods are used.

    Diagnostics

    If acute viral hepatitis B is suspected, a clinical blood test with a leukocyte count can be prescribed to timely identify complications and emergencies and assess the severity of the disease, and a general urinalysis to assess the level of bilirubin metabolites.

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    Methods for diagnosing viral hepatitis B

    Polymerase chain reaction (PCR) is a method that detects the genetic material (DNA) of a virus in a biomaterial.

    Hepatitis B virus, DNA (HBV, PCR) plasma, quality

    The study allows to detect hepatitis B virus in the patient’s blood. It is used to diagnose hepatitis B at early stages.

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    Serological methods detect antigens, that is, viral proteins, and antibodies to them, protein substances that the immune system produces to repel the attack of the virus.

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    After infection, surface antigen 9 is detected in the blood0068 ( HBsAg ) and infectivity antigen ( HBeAg ). They indicate the stage of the infectious process:

    The HBsAg** antigen indicates infection with the hepatitis B virus. It is detected already during the incubation period of hepatitis B and in the first 4–6 weeks after the onset of symptoms of the disease, then it ceases to be detected. If HBsAg is present in the patient’s blood for more than 6 months, this may indicate the transition of the disease to a chronic form.

    The HBeAg** antigen in the blood indicates the active reproduction of the virus in the body and the infectivity of a person. It is detected during the incubation period and at the first signs of the disease, then disappears. If a high level of HBeAg persists for 3-4 weeks of illness, this indicates a threat of hepatitis B transition to a chronic form.

    HBcoreAg antigen is found only in liver cells. It cannot be detected with a blood test.

    The body produces specific antibodies to all three antigens of the virus.

    Anti-HBs antibodies begin to circulate in the blood when recovery from the acute phase of the disease occurs. They are usually detected 3-4 months after the disappearance of HBsAg. At this time, as a rule, the window phase ends – a state when neither the viral HBs antigen nor antibodies to it are found in the blood of the infected person. The appearance of anti-HBs antibodies usually indicates the formation of immunity to the hepatitis B virus. The same antibodies are detected in the blood after vaccination against the hepatitis B virus.

    HBcoreAg class M (IgM) nuclear antigen antibodies are produced at the end of the incubation period and circulate in the blood when symptoms of the disease appear. In the future, after 4-6 months, they are replaced by antibodies of class G (IgG) – with the longest circulation in the blood: they can remain in the recovered person for life. The study of these antibodies is used as part of a comprehensive diagnosis to establish the presence of hepatitis B and determine its stage: acute, chronic infection or past illness.

    Analysis of anti-HBe antibodies as part of a comprehensive study allows you to monitor the course of acute hepatitis B and predict the further development of the disease. Thus, the rapid disappearance of the HBeAg antigen from the blood and the increase in the anti-HBe titer practically eliminates the threat of hepatitis B becoming chronic. If the HBeAg antigen continues to be detected in the blood for more than 3-4 weeks, this may indicate the development of chronic hepatitis B.

    Treatment of hepatitis B

    For acute hepatitis B, a doctor may prescribe a course of antiviral drugs for 3 to 6 months. After completion of treatment, maintenance therapy is usually recommended for 12 months.

    For patients with acute hepatitis B, it is very important to maintain a diet, maintain a balance of nutrients, replenish fluid losses caused by vomiting and diarrhea.

    In chronic hepatitis B, antiviral drugs can be prescribed that suppress the reproduction of the virus, help slow the development of cirrhosis of the liver and reduce the risk of developing liver cancer.

    As a rule, drug treatment can suppress the reproduction of the virus, but does not lead to a complete cure, so most patients take antiviral drugs throughout their lives.

    Diet and regimen for hepatitis B

    Patients with acute hepatitis B are recommended bed rest and a light diet. This means that fried, smoked, pickled dishes and fatty meats like pork or lamb should be excluded from the diet. Also, with acute hepatitis B, it is strictly forbidden to drink alcohol.

    After recovering from an acute illness, for at least another six months, you need to follow a daily routine and adhere to a sparing diet.

    Everything spicy, fried, smoked, alcohol, strong tea and coffee, pastries, fatty meats, broths, animal fats, spinach, onions, radishes, radishes, cranberries, cakes, cream, ice cream, carbonated drinks, chocolate are excluded from the diet.

    It is important to process the rest of the products correctly: steam them, boil, stew or bake them.

    Meals are served warm, eaten frequently – 5 times a day.

    Prevention of viral hepatitis B

    Since the possible complications of chronic hepatitis B in some patients – cirrhosis and liver cancer – are deadly, the World Health Organization recommends preventive vaccination against the virus.

    An effective way to prevent hepatitis B is vaccination

    The hepatitis B virus vaccine was developed in 1987. The campaign to immunize people against hepatitis B around the world began on 1990s, and by 2019, 85% of people worldwide have already received three doses of the vaccine.

    The most effective hepatitis B vaccination schedule is intramuscular administration of three doses of the vaccine at intervals:

    • The first dose is given on the first day of life, preferably within the first 12 hours.
    • The child receives the second dose one month after the first vaccination.
    • The third dose should be given 6 months after the start of vaccination.