HEPATITIS B IMMUNIZATION CONSENT OR REFUSAL FORM
Hepatitis B is a viral infection caused by Hepatitis B Virus (HBV) which causes death in 1%-2% of patients. Most people with Hepatitis B recover completely, but approximately 5%-10% become chronic carriers of the virus. Most of these people have no symptoms but can transmit the disease to others. Some may develop chronic active Hepatitis and Cirrhosis. HBV also has a role in the development of liver cancer. Immunization against Hepatitis B can prevent acute Hepatitis B and also reduce sickness and death from chronic active hepatitis, cirrhosis, and liver
The vaccine is produced from yeast cells that are inoculated with the Hepatitis B virus antigen. Over 90% of healthy people who receive three doses of the vaccine achieve protection against Hepatitis B. Full immunization requires three doses of vaccine over a six (6) month period. Immunity may not develop after three doses. A few persons may not develop immunity even after six doses. There is no evidence that the vaccine has ever caused Hepatitis or AIDS.
Incidence of side effects is generally low. Frequency of adverse reactions tends to decrease with successive doses.
1. Injection site soreness and fatigue are the most common adverse reactions. 2. Less common local reactions are redness, swelling, or an area of hardness. 3. General complaints, including dizziness, weakness, headaches, and fever occur occasionally. 4. Muscle or joint pains, nausea, vomiting, respiratory symptoms or chills are rare.
1. Hypersensitivity to yeast, aluminum, or mercury (components of vaccine 2. Hepatitis B Vaccine is given to pregnant women only if clearly indicated. 3. Presence of any serious active infection. NOTE: Hepatitis B has a long incubation period. Vaccination may not prevent Hepatitis B infection in those who have unrecognized infection at the time of vaccine administration.
I have read the above statement about Hepatitis and the Hepatitis B Vaccine. I have had an opportunity to ask questions and understand the benefits and risks of Hepatitis B vaccination. I understand that I must have three (3) doses of vaccine to confer immunity. However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side effect from the vaccine.