The four main approaches to immunisation against hepatitis B are: vaccination of high risk babies; universal adolescent immunisation; universal infant immunisation; and vaccination of everybody. Universal antenatal screening would permit identification of carrier mothers and immunisation of their babies. Vaccination of adolescents would provide protection close to the time when risk of exposure increases, and could be delivered as part of a wider package on health education. Universal vaccination of infants is the best option because it is known that vaccines can be delivered to babies and it is more acceptable to parents. Development of a combined hepatitis B-diphtheria-pertussis-tetanus vaccine would be beneficial. The identification of hepatitis B antibody escape mutants is of concern because of the implications for vaccine efficacy. Altered or absent expression of the hepatitis B virus (HBV) antigenic group determinant a may allow infection even in subjects who have responded previously to vaccination.
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