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The Sports Physical: A Good Time for 'Hep B' Shots?


The start of school signals another round of preparticipation physical examinations for athletes. Because the preparticipation exam is the only regular contact many teens have with the medical system (1), it can be an opportune time to cover routine health matters such as assessing a student's hepatitis B immunization status.

Many teenagers have not received hepatitis B vaccinations because the universal immunization recommendation was not in place when they were younger. In 1991 the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) recommended infant immunization as a means of eradicating hepatitis B (2). In January 1996, the group amended the schedule to include hepatitis B vaccination for 11- and 12-year-olds who were not immunized as infants (3).

Because of their changing behaviors, young people entering their teens have a higher risk of contracting hepatitis B, a fairly common liver disease spread through contact with blood, saliva, or semen. Most at risk are those who are sexually active, share personal items like razors and toothbrushes, use intravenous drugs, or get tattoos or body piercings with unsterile needles. The CDC estimates there are 1 million carriers of hepatitis B in the United States. The risk for spreading hepatitis B through sports contact, however, is tiny in comparison with the risk in off-the-field activities (4). Among sports, contact and collision sports carry the highest risk, but only one case of sports-related hepatitis B transmission has been reported in the medical literature—among sumo wrestlers in Japan (5).

Certain barriers could limit the use of the preparticipation exam to help stop hepatitis B. First, immunization requires three intramuscular injections, with the second and third doses administered 1 and 6 months after the first. Will teens return for follow-up shots? Second, there are no firm guidelines on reviewing a student's hepatitis B immunization status at the preparticipation exam, says pediatrician Suzanne M. Tanner, MD, assistant professor of pediatrics at the University of Colorado Health Sciences Center in Denver and editorial board member of The Physician and Sportsmedicine. "There's a debate about whether to immunize all teens or only high-risk ones," she says.

When middle school students in San Francisco were offered hepatitis B vaccinations at school, more than 95% of those who received the first dose completed the series. At first, students were rewarded with school items and a dance. However, a questionnaire revealed that the desire to be protected from hepatitis B outweighed gifts and dances as motivators (6). School district nurse Lynda Boyer-Chu, RN, MPH, who coordinated the demonstration project, said that she believes the high completion rate was due to the school-based population, which created a captive audience. Unless schools provide all three shots on site, she suggests giving athletes the first shot at a primary care physician's office to allow tracking of return visits for the second and third shots. Athletes who receive the first dose from an unfamiliar team physician or clinic may be less likely to get the remaining two shots, she says.

Another obstacle is the cost of the vaccine, which is $25 to $55 a dose. "Everybody wants to immunize children against hepatitis B. What people struggle with is who pays," says Gregory L. Landry, MD, a professor of pediatrics at the University of Wisconsin Medical School and an editorial board member of The Physician and Sportsmedicine. Landry says he feels uncomfortable telling financially strapped schools that all athletes must be immunized.

The two hepatitis B vaccines available contain no live viruses and carry few side effects. More than 6,000 immunizations were given in the San Francisco school study, and just two mild allergic reactions occurred, says Boyer-Chu.


  1. Krowchuk DP, Krowchuk HV, Hunter DM, et al: Parents' knowledge of the purposes and content of preparticipation physical examinations. Arch Pediatr Adolesc Med 1995;149(6):653-657
  2. Advisory Committee on Immunization Practices: Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee. MMWR 1991;40(RR-13):1-19
  3. Centers for Disease Control and Prevention: Recommended childhood immunization schedule, United States, January-June 1996. MMWR 1996;44(51 and 52):940-943
  4. Mast EE, Goodman RA, Bond WW, et al: Transmission of blood-borne pathogens during sports: risk and prevention. Ann Intern Med 1995;122(4): 283-285
  5. Kashiwagi S, Hayashi J, Ikematsu H, et al: An outbreak of hepatitis B in members of a high school sumo wrestling club. JAMA 1982;248(2):213-214
  6. Centers for Disease Control and Prevention: Hepatitis B vaccination of adolescents: California, Louisiana, and Oregon, 1992-1994. MMWR 1994;43 (33):605-609

Carol Potera
Great Falls, Montana