What vaccinations (hepatitis B series and immune globulin, tetanus booster, and HPV vaccine) should be given to a survivor of sexual assault, taking into account her age and timing of exposure?

Vaccination After Sexual Assault

Sexual assault survivors should receive hepatitis B vaccine (and HBIG if the assailant is HBsAg-positive or status unknown and the survivor is unvaccinated), tetanus booster (Td/Tdap if >5 years since last dose or vaccination history uncertain), and HPV vaccine (if age 9-26 years and not previously vaccinated or series incomplete) at the initial visit. 1

Hepatitis B Vaccination and Immune Globulin

The hepatitis B prophylaxis strategy depends critically on three factors: the survivor's vaccination status, the assailant's HBsAg status, and timing of presentation.

For Unvaccinated Survivors:

• If assailant is HBsAg-positive: Administer both HBIG (0.06 mL/kg IM) and initiate hepatitis B vaccine series immediately, preferably within 24 hours but no later than 7 days for percutaneous exposure or 14 days for sexual exposure 1, 2
• If assailant's HBsAg status is unknown: Initiate hepatitis B vaccine series as soon as possible (preferably within 24 hours); HBIG is not required 1
• The vaccine and HBIG should be administered at separate anatomic sites (different limbs) 1, 3
• Complete the 3-dose series at 0,1-2, and 6 months 2

For Previously Vaccinated Survivors:

• If series was completed but no post-vaccination testing was done: Administer a single booster dose of hepatitis B vaccine 1
• If series was incomplete: Complete the remaining doses and administer HBIG if the assailant is HBsAg-positive 1
• If documented vaccine responder (anti-HBs >10 mIU/mL): No additional treatment needed 1

Critical timing consideration: Studies show efficacy decreases markedly if HBIG treatment is delayed beyond 48 hours for perinatal exposure 3, and the interval for sexual exposure prophylaxis effectiveness is unlikely to exceed 14 days 1, 4.

Tetanus Prophylaxis

Tetanus vaccination depends on the survivor's immunization history and wound characteristics (if present).

For Tetanus-Prone Wounds (contaminated, deep, or delayed presentation):

• If last tetanus booster was >5 years ago or history uncertain: Administer Td or Tdap 5
• Adults aged 11-64 years who haven't received Tdap: Give Tdap instead of Td 5
• Adults >65 years: Give Td 5

For Clean, Minor Wounds:

• Booster only needed if >10 years since last dose 5

For Uncertain or Incomplete Primary Series:

• Complete the 3-dose primary series (doses at 0,4+ weeks, and 6-12 months after second dose) 6
• If TIG is indicated but supplies are limited: Reserve for patients >60 years or immigrants from regions other than North America/Europe who are least likely to have adequate protection 5

Important caveat: In mass casualty or resource-limited settings, failure to provide tetanus vaccination when needed could result in preventable illness, whereas unnecessary vaccination is unlikely to cause harm 5. When vaccination history cannot be confirmed, err on the side of administering the booster.

HPV Vaccination

HPV vaccination should be offered based on age, regardless of sexual assault history or current sexual activity status.

Age-Based Recommendations:

• Ages 9-26 years: Initiate or complete the HPV vaccine series 7, 8
• Ages 9-14 years at first dose: 2-dose series at 0 and 6-12 months 8
• Ages 15-26 years at first dose: 3-dose series at 0,1-2, and 6 months 9, 8

The AAP specifically recommends initiating the HPV series at age 9 years and older for children and youth with any history of sexual abuse or assault who have not initiated or completed the series 8, 7. This is a critical recommendation because:

• HPV infection rates are remarkably high after sexual initiation (nearly 40% within 2 years among college women) 8
• The vaccine is most effective when given before HPV exposure 9
• Even sexually active individuals benefit from vaccination as they are unlikely to have been infected with all vaccine HPV types 9
• Antibody responses are highest in younger adolescents (ages 9-15 years) 9

Special Considerations:

• History of abnormal Pap test or known HPV infection: Still vaccinate—the vaccine protects against types not yet acquired 9
• Pregnancy: Defer subsequent doses until after delivery 9
• Immunocompromised: Can receive vaccine but use 3-dose series regardless of age 8

Practical Implementation Algorithm

At the initial sexual assault examination:

1. Assess hepatitis B status:

   • Check vaccination records
   • If unvaccinated or incomplete series → start/complete series
   • If assailant HBsAg-positive → add HBIG
   • If fully vaccinated without testing → give single booster

2. Assess tetanus status:

   • If uncertain history or >5 years since last booster → give Td/Tdap
   • Consider wound characteristics

3. Assess HPV status:

   • If age 9-26 years → initiate or complete series
   • Use 2-dose schedule if age 9-14 at first dose
   • Use 3-dose schedule if age ≥15 at first dose

Common pitfall: Research shows that only 4.5% of sexual assault survivors received appropriate HBV prophylaxis, and up to 45.5% of adolescents tested had non-protective HBsAb levels 10. Additionally, completion rates for vaccine series are poor (38-47%) when follow-up is required 11. Therefore, administer all indicated vaccines at the initial visit rather than deferring to follow-up appointments.

Another critical pitfall: Do not delay hepatitis B vaccine administration while waiting for serologic testing results. The first dose should be given at the time of testing 2, and subsequent doses adjusted based on results if needed.