If Youve Had the Hepatitis Vaccines Do You Ever Need Them Again

Hepatitis A

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Disease Problems

What is hepatitis A?

Hepatitis A is a liver illness common in many parts of the world and caused past hepatitis A virus (HAV), a picornavirus that causes acute inflammation of the liver. Information technology is not related to the common viruses that cause hepatitis B or C.

What are the signs and symptoms of hepatitis A?

Disease caused past HAV infection cannot be distinguished from other types of acute viral hepatitis, but information technology typically has an precipitous onset that can include fever, malaise, anorexia, nausea, intestinal discomfort, night urine, and jaundice. The likelihood of having symptoms with HAV infection is related to historic period. In children younger than age 6 years, 70% of infections are asymptomatic. When illness does occur in immature children, it is typically not accompanied by jaundice. In older children and adults, infection typically is symptomatic, with jaundice occurring in more than lxx% of patients.

Hepatitis A signs and symptoms usually resolve in 2-3 months, although 10% to 15% of symptomatic people take prolonged illness (usually referred to as relapsing hepatitis A) lasting upwards to 6 months and should be considered infectious during that fourth dimension.

How is HAV transmitted?

Person-to-person spread through the fecal-oral route is the master means of HAV transmission. Acme infectivity in infected people occurs during the two week menses before the onset of jaundice when the concentration of virus in the stool is highest and about people are no longer infectious one calendar week afterwards jaundice onset. Earlier routine vaccination of children was recommended, children were a cardinal source of infection considering almost infected children had no symptoms and could shed virus in stool for weeks or months. Transmission currently occurs primarily amongst susceptible adults.

Common-source outbreaks and sporadic cases tin occur from exposure to fecally-contaminated nutrient or water. Uncooked HAV-contaminated foods have been recognized as a source of outbreaks. Cooked foods also can transmit HAV if the temperature during food preparation is inadequate to kill the virus or if food is contaminated after cooking, as occurs in outbreaks associated with infected nutrient handlers. Transmission of the virus from infected food handlers to food service establishment patrons is rare, accounting for 0.ii% of the nearly 23,000 outbreak-associated cases of hepatitis A investigated past state wellness departments during 2016-2019.

Until 2017, United states incidence rates of hepatitis A were driven by occasional outbreaks, often linked to viral contagion of imported food. Since 2017, communitywide outbreaks have occurred more frequently, predominantly amidst people who are connected by specific risk factors, such as drug use, and their close contacts.

What is the incubation period for hepatitis A?

HAV tin can produce either asymptomatic or symptomatic infection in humans subsequently an boilerplate incubation period of 28 days (range: fifteen–l days).

How is HAV shed?

In infected people, HAV replicates in the liver, is excreted in bile, and is shed in stool. Peak infectivity occurs during the two-week period before onset of jaundice or elevation of liver enzymes, when concentration of virus in stool is highest. Concentration of virus in stool declines afterward jaundice appears, with nearly people no longer infectious near a week after jaundice appears. Children tin can shed HAV for longer periods than adults, up to ten weeks or longer after onset of clinical illness.

How common is HAV infection in the United States?

The incidence of hepatitis A in the US increased more than than 10-fold from 2015 to 2019, with over 18,800 cases reported to CDC in 2019. This number is an underestimate of the actual number of infections: CDC estimates that almost 37,700 cases actually occurred in 2019.

Between 2012 and 2015 the number of reported hepatitis A infections ranged from approximately 1200 to 1800 cases every year. Beginning in 2016, large foodborne outbreaks led to an increase in the number of cases and sustained, large person-to-person outbreaks began, primarily driven past infections amongst unvaccinated people who apply drugs and people experiencing homelessness and their contacts. Since then, persistent person-to-person outbreaks accept led to substantial increases in hepatitis A infection, with reported cases increasing by over 50% from 2018 to 2019. More data regarding ongoing multistate outbreaks can be found here: www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Do people dice from hepatitis A?

Yes. Death equally a consequence of fulminant hepatic failure is rare, however, older historic period (over twoscore years) and preexisting chronic liver illness increases the gamble of severe illness and death from hepatitis A. The person-to-person U.Due south. multistate outbreaks that began in 2016 accept disproportionately affected adults with chronic liver disease and other wellness issues related to drug employ and unstable housing. From 2016 through Nov 2021, CDC received reports of nearly 43,000 cases of acute HAV infection. Of these, approximately 61% accept been hospitalized and 1% (more than 400 people) accept died.

Who is most at risk for acquiring HAV infection?

People who are at increased risk for acquiring HAV infection include the following:

• Travelers to countries that have high or intermediate endemicity of HAV infection • Men who have sex with men (MSM) • Users of injection and non-injection drugs (in other words, all who employ illegal drugs) • People with occupational risk of exposure (those who piece of work with HAV-infected non-human being primates or researchers handling hepatitis A virus) • People who anticipate close contact with an international adoptee coming from a state with high or intermediate endemicity of HAV infection • People living with HIV infection • People experiencing homelessness, including temporary shelters and other unstable living arrangements • People living in group settings for those with developmental disabilities and other settings where hygiene is difficult to maintain • People who are incarcerated

I thought people with clotting cistron disorders were at risk for hepatitis A due to their regular utilise of claret products. Why did ACIP decide to stop recommending routine vaccination of people with clotting cistron disorders?

People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that fourth dimension, the process used to brand clotting factor supplements did non reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of HAV infection. Modern blood donor screening and virus reduction steps accept drastically reduced that risk. In improver, more than 80% of people with clotting factor disorders at present receive recombinant clotting factor concentrates that are sterilized and take no risk of HAV manual. As a result of these factors, people with clotting factor disorders now have no greater risk of hepatitis A than the full general population and are no longer recommended to receive HepA vaccine unless information technology is otherwise indicated.

Are people with developmental disabilities at risk of HAV infection?

Historically, HAV infection was highly owned in institutions for people with developmental disabilities every bit a result of poor hand hygiene, close living conditions and diaper utilise. Every bit fewer children have been institutionalized and as conditions in institutions have improved, the incidence and prevalence of HAV infection have decreased, although outbreaks tin occur in these settings. All children with developmental disabilities should receive HepA according to U.S. routine vaccine recommendations, including catch up vaccination of all children through age 18 years.

As a strategy to further reduce the gamble of hepatitis A outbreaks and reach adults in settings with a high proportion of people with adventure factors for HAV infection, the current ACIP recommendations propose considering HepA vaccination of residents and staff in facilities where hygiene is difficult to maintain, such equally grouping homes for people with developmental disabilities and homeless shelters.

Are people with chronic liver disease at higher run a risk of acquiring HAV infection?

No. People with chronic liver illness are not at increased adventure for acquiring HAV infection. However, they are at an increased take chances for life-threatening, fulminant (severe and sudden) hepatitis if they become infected with hepatitis A. People considered to have chronic liver illness include those with hepatitis B or C infection, cirrhosis, fat liver illness, alcoholic liver disease, and autoimmune hepatitis.

Please discuss the tests commonly used to diagnose hepatitis A.

Hepatitis A cannot be differentiated from other types of viral hepatitis on the ground of clinical or epidemiological features alone. Appropriate blood tests must be used.

• Anti-HAV: Total antibiotic to HAV. This diagnostic exam detects full antibody of both IgG and IgM subclasses of HAV. If positive, it indicates either acute or resolved infection. • IgG anti-HAV: IgG antibody is a bracket of anti-HAV. It appears early on in the course of infection, remains detectable for the person's lifetime and provides lifelong protection against disease. Its presence indicates immunity through either HAV infection or HepA vaccination. • IgM anti-HAV: IgM antibody is a subclass of anti-HAV. Its presence indicates a contempo infection with HAV (half dozen months or less). It is used to diagnose acute (recently acquired) hepatitis A. Considering of the risk of faux positive IgM anti-HAV results, people should just exist tested for IgM anti-HAV if they are symptomatic and suspected of having acute hepatitis A illness. • HAV RNA tests also may be used to diagnose acute infection through the direct detection of viral RNA in serum or stool.

Total anti-HAV, which appears early in the form of infection, remains detectable for the person's lifetime and indicates lifelong protection against the infection/disease. To confirm a diagnosis of astute HAV infection, serologic testing for IgM anti-HAV is required. In the majority of persons, serum IgM anti-HAV becomes detectable 5 to ten days earlier onset of symptoms and lasts about 6 months. However, there have been reports of persons who test positive for IgM anti-HAV for upwardly to a year or more following infection. An educational programme on the estimation of hepatitis A serology is available on the CDC website at www.cdc.gov/hepatitis/resource/professionals/grooming/serology/preparation.htm.

Can HAV be transmitted past claret?

Yes. On rare occasions, HAV infection has been transmitted by transfusion of blood or blood products nerveless from donors during the viremic stage of their infection (i.east., when HAV is in the donor'south blood). Since 2002, tests to detect the presence of hepatitis A virus RNA in donated plasma have drastically reduced the risk of hepatitis A manual from products derived from blood plasma.

Is HAV transmitted by saliva?

In experimentally infected nonhuman primates, HAV has been detected in saliva during the incubation catamenia; however, transmission past homo saliva has not been reported.

How common is HAV transmission in infirmary settings?

Hospital-acquired HAV infection is rare. In the by, outbreaks were observed in neonatal intensive care units when infants acquired infection from HAV-infected transfused claret and subsequently transmitted HAV to other infants and staff. Outbreaks of hepatitis A caused by transmission from adult patients to healthcare personnel (HCP) are typically associated with fecal incontinence and inadequate hand hygiene, although the majority of hospitalized patients who have hepatitis A are admitted afterwards onset of jaundice, when they are across the indicate of height infectivity. Manual in healthcare settings too has resulted from breakdowns in standard infection control practices and transmission from i healthcare provider to another.

How stable is HAV in the environs?

Depending on weather, HAV can exist stable in the environment for months; freezing does not inactivate (i.e., render non-infectious) HAV. HAV is inactivated by heating foods to temperatures greater than 185°F (85°C) for 1 minute. In add-on, HAV on surfaces is inactivated by disinfecting surfaces with a ane:100 dilution of sodium hypochlorite (i.eastward., household bleach) in tap water.

Adequately chlorinating water through water treatment processes and dilution in public h2o systems kills HAV. Spas and swimming pools that are adequately treated are not likely to pose a chance for HAV outbreaks.

Do people with hepatitis A develop chronic disease or can they get repeated infections?

No, there is no chronic (long-term) infection. Even the minor proportion of people who develop relapsing HAV recover after near six months. Once you have had HAV infection and recovered, you cannot get information technology once more.

Vaccination Recommendations Back to pinnacle

What is the best way to foreclose HAV infection?

Vaccination with the total series of hepatitis A vaccine (HepA) is the best style to prevent HAV infection. Allowed globulin (IG) also can be used for curt-term protection in sure situations.

What are the hepatitis A vaccines (HepA) that are approved for apply in the U.s.?

Recommended dosages and schedules of hepatitis A vaccines Vaccine Age group Dose Volume # Doses Schedule Havrix (GSK) 1-18 years 720 El.U.* 0.5 ml 2 0, half dozen-12 mos. 19 years and older 1440 El.U.* 1.0 ml two 0, 6-12 mos. Vaqta (Merck & Co.) i-18 years 25 U** 0.5 ml 2 0, half dozen-18 mos. 19 years and older 50 U** 1.0 ml 2 0, six-xviii mos.

*El.U. = Elisa Units **U = Units

Combination vaccine using hepatitis A and hepatitis B vaccines Vaccine Age group Antigens used Volume # Doses Schedule Twinrix (GSK) xviii years and older Havrix (720 El.U.) combined with Engerix-B (20 mcg) 1.0 ml 3 0, one, 6 mos. 4 0, 7, 21-thirty days, 12 months***

*** Accelerated schedule may exist used for rapid protection prior to travel or for rapid protection of an unexposed but at-chance person who also would do good from hepatitis B protection. Twinrix is not recommended for use every bit post-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

Yep, a number of studies signal that the two brands of HepA, Havrix (GSK) and Vaqta (Merck), are interchangeable.

Where can I find data almost vaccine shortages?

For detailed information most HepA shortages, go to CDC'south website at world wide web.cdc.gov/vaccines/hcp/clinical-resource/shortages.html.

Who is recommended to receive HepA vaccine?

The Advisory Committee on Immunization Practices (ACIP) recommends routine HepA vaccination for the post-obit groups:

• All children at historic period 1 year (12–23 months) • All children and adolescents age 2 through xviii years who take not previously received HepA should exist vaccinated (i.eastward., routine catch-up vaccination) [2020] • People living with HIV infection [2020] • Travelers age 12 months and older to areas of the earth with intermediate or high HAV endemicity. Low endemicity regions include the United States, Canada, Western Europe, Nippon, New Zealand, and Australia. For more information, see the CDC travel health website for electric current information about specific countries at www.cdc.gov/travel or the CDC Yellow Volume (wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-a). When in doubt, vaccinate. • Infants age half-dozen through 11 months traveling outside the U.s. should receive 1 dose when protection against HAV infection is recommended. The travel dose does not count toward the routine HepA series which should be initiated at historic period 1 year with the advisable dose and schedule. In these instances, the kid will receive a full of 3 doses of HepA vaccine. • Men who have sex with men • Users of illegal drugs, injectable or noninjectable • People who are homeless or in unstable living arrangements, including shelters • Previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee'south arrival in the U.S. • People who piece of work with HAV-infected nonhuman primates or with HAV in a research laboratory setting • People with chronic liver disease (including but non limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or an ALT or AST level persistently greater than twice the upper limit of normal) • People identified during pregnancy to be at run a risk for HAV infection due to presence of a specific risk factor for exposure or at take a chance for severe consequence from HAV infection (for example, those with chronic liver affliction or with HIV infection). • During an outbreak, any unvaccinated person who is identified equally at risk for HAV infection or at risk for astringent disease from HAV • Any person who wishes to be immune to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, food handlers, sewage workers, or twenty-four hour period care providers considering there is no testify that their occupational risks of HAV exposure are significantly higher than the general population. Nonetheless, any person who desires protection from HAV infection may be vaccinated.

For details about CDC recommendations for the prevention of hepatitis A, encounter the 2020 recommendations of the Advisory Committee on Immunization Practices (ACIP): www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

What groups of people recommended for routine HepA vaccination were added or removed in the July 2020 ACIP statement?

• [added] All children ages 2 through xviii years not previously vaccinated • [added] All people age 1 year or older living with HIV infection • [added] People identified to be at hazard for HAV infection during pregnancy • [removed] People with clotting factor disorders

Should nosotros give HepA to a person older than age 18 years who requests it?

Yes, unless the person is allergic to any of the vaccine components. HepA vaccination is safe and effective and is recommended for any person who wishes to obtain immunity.

Which children should be routinely vaccinated confronting HAV infection?

All children should receive two doses of HepA vaccine beginning at age 1 year (i.e., 12–23 months). The 2 doses in the series should exist administered at least half-dozen months apart. Whatever child age 2 through 18 years not previously vaccinated should be vaccinated. For a re-create of the ACIP recommendations on hepatitis A, go to world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

For hepatitis A vaccination, the minimum interval between the two-dose series is at to the lowest degree 6 months. Is this the same as 24 weeks?

No. The minimum interval between dose #1 and #2 of HepA vaccine is six calendar months, non 24 weeks.

I have a child who was given her second dose of hepatitis A vaccine 4 months later the first dose. Does it demand to be repeated, and if and then, when?

Yeah. The second dose was given more than iv days before the minimum interval of half dozen calendar months, then it is considered invalid and should be repeated. The echo dose should be administered the proper minimum interval (6 months) later on the invalid dose. If this repeat dose is inadvertently given less than 6 months subsequently the invalid dose, it does not need to be repeated again every bit long as the interval betwixt the initial HepA vaccine and the about recent dose is at to the lowest degree 6 agenda months.

What are the recommendations for postexposure prophylaxis (PEP) for hepatitis A?

In 2020, CDC published revised recommendations for hepatitis A postexposure prophylaxis (PEP). Please see the consummate PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attending to Tabular array 4 on page 19 and Appendix B: Provider Guidance on Hazard Cess for Hepatitis A Postexposure Prophylaxis, start on page 36.

Good for you people who have completed the HepA vaccination series at any time practise not need additional PEP if they are exposed to HAV. People who have recently been exposed to HAV and who have not received HepA vaccine previously should receive PEP as soon as possible, inside ii weeks of exposure.

People age 12 months and older exposed to HAV inside the by 14 days and who have not previously completed the HepA vaccine series should receive a unmarried dose of HepA vaccine as soon every bit possible. In addition to vaccine, immune globulin (IG; 0.ane mL/kg) may be administered to people older than age 40 years depending on the providers' risk assessment. For long-term immunity, the HepA vaccine serial should be completed with a second dose at to the lowest degree 6 months later on the offset dose. However, the second dose is not necessary for PEP. A second dose should non be administered sooner than 6 calendar months afterwards the first dose, regardless of HAV exposure gamble.

People age 12 months or older who are immunocompromised or have chronic liver illness, and who have been exposed to HAV within the by 14 days and accept not previously completed the HepA vaccination series, should receive both IG (0.ane mL/kg) and HepA vaccine at the same visit in a different anatomic site (for case, divide limbs) as presently as possible after exposure. For long-term immunity, the HepA vaccination series should exist completed with a 2d dose at least 6 months after the first dose. Nonetheless, the second dose is non necessary for PEP. A second dose should not be administered sooner than half-dozen agenda months subsequently the starting time dose, regardless of HAV exposure chance.

People with HIV infection develop protective levels of antibody more slowly and are less likely to develop protective antibody levels afterward vaccination with HepA, especially if their CD4+ count is low at the fourth dimension of vaccination. Protection following vaccination of a person with HIV may wane over time. Vaccine should exist administered if the exposed individual is not fully vaccinated; notwithstanding, CDC also advises clinicians to consider administering IG PEP to an individual with HIV after a high-risk exposure (such equally a household or sexual contact) even if the individual has been fully vaccinated.

Twinrix contains half the amount of hepatitis A antigen as a standard unmarried-dose adult HepA vaccine. Twinrix should not be used for PEP only may be used to confer protection to at-risk merely not nevertheless exposed persons during an outbreak.

Infants younger than historic period 12 months and persons for whom vaccine is contraindicated should receive IG (0.i mL/kg) instead of HepA vaccine as before long every bit possible and inside 2 weeks of exposure. MMR and varicella vaccines should not be administered sooner than half dozen months after IG administration in order to avoid possible IG interference with the effectiveness of MMR and varicella vaccines.

When should prevaccination anti-HAV testing for susceptibility exist performed?

Prevaccination serologic testing for HAV (measuring either full anti-HAV or IgG anti-HAV) is non indicated for children because of the low prevalence of infection in children. It also is not routinely recommended for adults merely may exist considered in some settings to reduce costs associated with vaccinating people who are already allowed. Prevaccination testing should not be used if it poses a barrier to vaccinating susceptible people, especially people who are difficult to access.

Prevaccination testing is virtually probable to be cost-effective for adults who were either born in or lived for long periods of time in areas of the world with high or intermediate hepatitis A endemicity. When evaluating people from populations with high rates of previous HAV infection, vaccination history also should be obtained, if feasible. If testing or vaccination history is not available, do not postpone vaccinating. At that place is no impairment in vaccinating a person who has had natural infection or previous doses of vaccine.

When should postvaccination testing be performed?

Serologic testing for amnesty is not necessary after routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibiotic one month or more after completing the HepA vaccination series is recommended just for people whose future clinical management depends on knowing their allowed status and for whom revaccination might be indicated, such as people living with HIV and other immunocompromised persons (such as transplant recipients and people vaccinated while receiving chemotherapy). In such individuals, if the results of postvaccination testing do non bear witness an acceptable immune response (10 mIU/mL or higher), revaccination with a complete series is recommended, followed by a second postvaccination serologic exam. If that second test remains negative, no additional vaccination is recommended; however, the patient should exist counseled on strategies to avoid exposure to HAV and the need for IG if an exposure occurs. If vaccination results in seroconversion, insufficient data are available to brand recommendations apropos repeat testing, booster doses or revaccination.

For Special Groups Back to top

Explain the details regarding the recommendation for giving HepA vaccine to people who will be in contact with recently adopted children.

ACIP recommends vaccination confronting HAV infection for all previously unvaccinated people who conceptualize having shut personal contact with an international adoptee from a country of loftier or intermediate endemicity during the outset 60 days following the adoptee'due south inflow in the U.S. In addition to the adoptee's new parents and siblings, this group might include grandparents, other household members, regular babysitters and other caregivers. The beginning dose of HepA should be given to close contacts as presently as adoption is planned, ideally at to the lowest degree 2 weeks before the arrival of the adoptee. A 2d dose should be given no sooner than 6 months later the first dose.

ACIP now recommends routine hepatitis A vaccination for people experiencing homelessness. Can you provide a definition of "experiencing homelessness"?

The 2020 ACIP recommendations for the prevention of hepatitis A define a person experiencing homelessness equally i) a person who lacks housing (regardless of whether the person is a member of a family), including a person whose principal residence during the dark is a supervised public or private facility (east.g., shelter) that provides temporary living accommodations and a person who is a resident in transitional housing, 2) a person without permanent housing who might: alive on the streets, stay in a shelter, mission, unmarried-room occupancy facility, abandoned building, vehicle, or any other unstable or nonpermanent situation, or 3) who is "doubled up", a term that refers to a situation where persons are unable to maintain their housing situation and are forced to stay with a series of friends or extended family unit members. In addition, previously homeless persons who are to be released from a prison or a hospital might exist considered homeless if they do not have a stable housing situation to which they can return. The instability of a person's living arrangements is critical to the definition of homelessness.

Some people on my team are worried near initiating the HepA vaccine serial in people who are homeless because nosotros may non be able to complete the series or go along upwardly with their records over time. How much of a business organisation is this?

While a complete serial of HepA is recommended for long-term protection, fifty-fifty a single dose of HepA vaccine has been demonstrated to provide protection against hepatitis A for more than than 10 years and can prevent or command outbreaks of hepatitis A. People who are experiencing homelessness may have difficulty protecting themselves from exposure to HAV in other ways because of their living conditions. They should exist vaccinated when possible and provided a record of immunization. Reporting the HepA vaccination to a state immunization data system too can facilitate immunization assessment at futurity healthcare encounters.

Should healthcare providers (HCP) be vaccinated routinely against hepatitis A?

No. A number of studies have shown that HCP are not at significantly increased risk of HAV infection because of their occupation. Withal, if HCPs are going to work (or holiday) in a country with a high or intermediate endemic charge per unit of HAV infection, they are at risk of HAV infection and should be vaccinated. The only occupational indications for routine HepA vaccination are piece of work with non-human primates or live HAV in a laboratory setting.

Should daycare workers exist routinely vaccinated confronting hepatitis A?

No. In the by, outbreaks of hepatitis A occurred among children in child care centers, infecting employees of those centers, especially those caring for infants and toddlers. Post-obit widespread adoption of early on childhood vaccination against hepatitis A, outbreaks in kid care centers are now rare.

Why is hepatitis A vaccination recommended for people with chronic liver disease?

Although not at increased hazard for HAV infection, people with chronic liver disease are at increased gamble for fulminant hepatitis A, hospitalization and expiry if they get infected with HAV. For this reason, hepatitis A vaccination is recommended for them.

Why isn't hepatitis A vaccination recommended for sewage and solid waste disposal workers?

In published reports of iii serologic surveys conducted among United States wastewater workers and appropriate comparison populations, no substantial or consistent increase in the prevalence of anti-HAV was identified among wastewater workers. No work-related instances of HAV transmission have been reported among wastewater workers in the The states. In improver, in the Usa, outbreaks of hepatitis A acquired by flooding, which can carry raw sewage, have not been reported.

Why is hepatitis A vaccination no longer recommended for people with clotting factor disorders?

People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that fourth dimension, the process used to brand clotting factor supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased chance of HAV infection. Modern claret donor screening and virus reduction steps have drastically reduced that adventure. In addition, more than 80% of people with clotting factor disorders now receive recombinant clotting factor concentrates that are sterilized and take no take a chance of HAV manual. As a result of these factors, people with clotting gene disorders now have no greater take chances of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless information technology is otherwise indicated.

Why is hepatitis A vaccination recommended (and IG not recommended) for babe travelers historic period vi through 11 months at take chances of exposure to HAV?

Because of measles. Measles is highly catching and poses a serious threat to the health of unvaccinated infants. For this reason, all infants age vi through eleven months who travel internationally are recommended to receive a dose of measles, mumps, and rubella vaccine (MMR) to reduce the hazard of measles infection during travel.

The antibodies in immune globulin (IG) typically used to prevent HAV infection in infants before the first birthday can interfere with the effectiveness of MMR vaccine. An baby who is given IG should not be vaccinated with MMR or varicella vaccines for at to the lowest degree half-dozen months after IG administration. If an infant historic period vi through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-label utilize of HepA vaccine (non IG) in addition to MMR. The HepA and MMR doses administered before the first birthday practise not count toward the routine vaccination serial of either vaccine: these infant travelers volition still demand two doses of HepA and two doses of MMR when age appropriate.

Can meaning women receive hepatitis A vaccine?

Yeah. The ACIP recommends that pregnant women at take a chance for HAV infection during pregnancy or at risk for a severe outcome from HAV infection should exist vaccinated during pregnancy if not previously vaccinated. Pregnant women should be vaccinated for the same indications every bit non-pregnant women. For additional data, come across page twenty of the recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Administering Vaccines Dorsum to top

Past what method should hepatitis A vaccine exist administered?

Hepatitis A vaccine (HepA) should be administered intramuscularly (IM), using the appropriate injection site and needle size as adamant by the patient'due south historic period and body mass.

Can HepA vaccine exist given meantime with other vaccines?

Yep. Other inactivated and/or alive virus vaccines tin can exist administered at the same time every bit HepA vaccine, just should be given at a different anatomical site, if possible. If given in the aforementioned musculus, separate the injections by a minimum altitude of i inch.

Is HepA vaccine available to children through the Vaccines for Children (VFC) program?

Yep, VFC-supported HepA vaccine is available for children 12 months through 18 years who are VFC-eligible. In add-on, combination HepA and HepB vaccine (Twinrix; GSK) is likewise bachelor for people who are age 18 years who are VFC-eligible.

What happens if dose #2 of HepA vaccine is delayed?

Yous do not need to showtime the serial once more. The immunogenicity of 1 dose of HepA vaccine is 94% to 100%; studies have shown persistent protection from a single dose lasting more than than ten years. To ensure optimal long-term protection it is of import to administrate the second dose.

To complete a 21-yr-erstwhile patient'south HepA vaccine serial, how many adult doses should I give if the patient received a single dose of pediatric HepA vaccine 5 years ago?

A person should receive the dosage of HepA vaccine appropriate for their age at the fourth dimension of administration. Yous should give the patient i adult dose of HepA to complete the 2-dose series. Information technology is non necessary to restart the vaccine series.

1 of our staff gave a dose of pediatric HepA vaccine to an adult patient by mistake. How practise we remedy this error?

In general, if the error is discovered on the same clinic day, y'all can administer the other "one-half" of the dose on that aforementioned twenty-four hours. If the error is discovered later on, the dose should not be counted, and so the person should be recalled to the office and given a total age-advisable repeat dose.

If you give more than an historic period-advisable dose (for example, an adult dose of HepA vaccine given to a kid), count the dose as valid and notify the patient/parent near the error. In that location may exist an increased risk of a local adverse reaction when more than than the recommended dose is given. If the error occurred with the first dose of the series the child should still receive the second dose on schedule. Giving a "double" dose for the first dose does non negate the demand for a second dose.

Avoid such errors by checking the vaccine vial characterization 3 times.

Why does a 15 year old who weighs 160 pounds receive a pediatric dose of HepA while his 110-pound mother receives an adult dose (twice the pediatric dose)?

The efficacy information from the clinical trials were based on age at fourth dimension of vaccination, and not on the weight of the individual. Hence, the dosage recommendations reflect this age-based efficacy data. The aforementioned holds true for HepB vaccine. In addition, higher response rates are expected in younger people, even if their weights are in a higher place the norm.

Could you please provide more information about Twinrix (the combination hepatitis A and B vaccine) and the 2 schedules for its use?

Twinrix (GSK) is an inactivated combination vaccine containing both hepatitis A virus (HAV) and hepatitis B virus (HBV) antigens. The vaccine contains 720 EL.U. of hepatitis A antigen (half of the Havrix adult dose) and 20 mcg of hepatitis B antigen (the full Engerix-B developed dose).

In the U.S., Twinrix is licensed for use in people who are age 18 years or older. It tin exist administered to people who are at take a chance for both hepatitis A and hepatitis B, such every bit certain international travelers, people with HIV infection, people with chronic liver affliction non caused by hepatitis B, men who have sex activity with men, illegal drug users, or to people who only want to be immune to both diseases. Primary immunization consists of 3 doses given intramuscularly on a 0, 1, and 6 month schedule. In 2007, the FDA also approved a 4-dose schedule for Twinrix. Information technology consists of iii doses given within 4 weeks, followed by a booster dose at 12 months (0, 7 days, 21–thirty days, and 12 months). The 4-dose schedule could benefit individuals needing rapid protection from hepatitis A and hepatitis B, such as people traveling to loftier-prevalence areas imminently.

Twinrix cannot exist used for postexposure prophylaxis.

I have seen adults who have had 1 or two doses of Twinrix, but nosotros only carry single-antigen vaccine in our practice. How should we consummate their vaccination series with unmarried-antigen vaccines?

Twinrix is licensed as a 3-dose series for people historic period 18 years and older. If Twinrix is not bachelor or if you choose not to use Twinrix to complete the Twinrix series, you should do the post-obit: If 1 dose of Twinrix was given, complete the series with 2 adult doses of hepatitis B vaccine and 2 adult doses of hepatitis A vaccine. If ii doses of Twinrix were given, complete the schedule with 1 adult dose of hepatitis A vaccine and 1 adult dose of hepatitis B vaccine.

Another style to consider this is as follows:

A dose of Twinrix contains a standard adult dose of hepatitis B vaccine and a pediatric dose of hepatitis A vaccine. Thus, a dose of Twinrix can be substituted for whatsoever dose of the hepatitis B series but not for any dose of the hepatitis A series.

• Whatsoever combination of 3 doses of adult hepatitis B or iii doses of Twinrix is a complete series of hepatitis B vaccine. • One dose of Twinrix + two doses of adult hepatitis A is a complete series of hepatitis A vaccine. • Ii doses of Twinrix + 1 dose of adult hepatitis A is a complete series of hepatitis A vaccine.

We're thinking of using Twinrix and we're wondering whether we tin use information technology for doses #one and #3 only and use single antigen hepatitis B vaccine for dose #2?

No. Twinrix contains 50% less hepatitis A antigen component than Havrix, GSK's monovalent hepatitis A vaccine [720 vs. 1440 El. U.], and so the patient would non receive the recommended dose of hepatitis A vaccine antigen. For this reason, 3 doses of Twinrix must comprise the series.

Allowed Globulin Dorsum to pinnacle

What is immune globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile preparation of concentrated antibodies (i.e., immunoglobulins) made from pooled human plasma candy by cold ethanol fractionation. GamaSTAN is the only IG product licensed in the U.s. for the prevention of hepatitis A. Simply plasma that has tested negative for hepatitis B surface antigen, antibody to human immunodeficiency virus (HIV), and antibody to hepatitis C virus (HCV) is used to produce IG. In addition, the Food and Drug Administration requires that the process used to produce IG include a viral inactivation stride or that final products test negative for HCV-RNA by polymerase chain reaction. Anti-HAV concentrations differ among IG lots and decreasing concentrations have been observed over the past xxx years, probably considering of the decreasing prevalence of previous HAV infection among plasma donors. In 2017, the dosing of GamaSTAN for HAV prevention was increased to reflect this modify in anti-HAV potency.

How does immune globulin (IG) work?

IG provides protection against HAV infection through passive transfer of antibody. Depending on the IG dosage, protection lasts from 1 to 2 months.

When administered for preexposure prophylaxis, a dose of 0.ane mL/kg will provide protection for upwardly to 1 calendar month and a dose of 0.two mL/kg will provide protection for up to 2 months. If longer term protection is required and vaccination is contraindicated, a dose of 0.2 mL/kg can be repeated every ii months. At that place is no maximum number of times the bimonthly doses of IG may exist repeated as long every bit hepatitis A prophylaxis is required.

For postexposure prophylaxis, the recommended dosage is 0.ane mL/kg.

How is IG packaged and how is IG administered?

Intramuscular IG is available in single-use vials (2 mL and 10 mL). Information technology should be administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Practice not use the gluteal region as an injection site considering of the hazard of injury to the sciatic nerve.

Does IG cause adverse events?

Serious adverse events from GamaSTAN IG are rare. Anaphylaxis has been reported afterward repeated assistants to people with known immunoglobulin A (IgA) deficiency; thus, IG should non be administered to these people. IG products including GamaSTAN have been associated with the formation of blood clots (thrombosis) after administration, particularly if the patient has other risk factors for thrombosis. Patients should be counseled about this risk.

Can meaning or lactating women receive IG?

Aye. Pregnancy or lactation is not a contraindication to IG administration if clearly needed.

A child in my exercise was given hepatitis A IG (GamaSTAN, Grifols) when she was x months sometime subsequently her mother tested positive for hepatitis A. She's scheduled for her 12-month-old well-child visit. Will this affect her vaccination schedule?

Yep. IG may be given any time before or after inactivated vaccines. All the same, the antibodies in IG may interfere with the effectiveness of certain live-virus vaccines, such as measles, mumps, and rubella (MMR) and varicella vaccines. CDC recommends waiting at least 6 months from the date of IG administration before administering MMR and varicella vaccines.

Which people should get GamaSTAN (IG) for prevention of hepatitis A?

Delight come across details of the recommendations for the use of IG for the prevention of hepatitis A provided in Table 4 (page nineteen) and Appendices A and B of the 2020 ACIP recommendations for the prevention of hepatitis A infection: world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Below is a cursory summary of the recommendations:

Preexposure prophylaxis with IG for travel to areas of intermediate or high hepatitis A endemicity:

• Infants younger than age 6 months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver disease vaccinated inside two weeks of departure may consider IG in addition to vaccination, based upon the clinician'southward risk cess • Previously unvaccinated people who are immunocompromised may consider IG in addition to vaccination, regardless of the timing of vaccination, based upon the clinician's risk cess • Previously unvaccinated people who are over age twoscore years and vaccinated within 2 weeks of departure may consider IG in addition to vaccination, based upon the clinician's risk cess

Postexposure prophylaxis with IG within 2 weeks later on exposure to hepatitis A virus (HAV):

• Infants under age 12 months • Previously unvaccinated immunocompromised adults (including HIV+), in add-on to vaccination • Previously unvaccinated adults with chronic liver affliction, in addition to vaccination • Previously unvaccinated adults over age 40 years, consider IG in addition to vaccination, based upon clinician risk assessment • People with HIV infection, previously vaccinated, consider IG following a high-risk exposure (household or sexual contact), based upon clinician risk assessment

Travel - International Dorsum to top

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people historic period vi months or older who are traveling to or working in an expanse of the world at intermediate or high risk of hepatitis A manual. Areas of low adventure include the U.s., Canada, Japan, New Zealand, Australia and Western Europe. Visit the CDC's Traveler Wellness website for more than information about specific destinations and current outbreaks or travel notices (https://wwwnc.cdc.gov/travel/). When in incertitude, vaccinate.

What are the recommendations for vaccination of travelers to protect them from hepatitis A virus (HAV) infection?

For details on preexposure protection of international travelers age 12 months and older, refer to Appendix A on folio 35 of the current ACIP recommendations for the prevention of hepatitis A: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Good for you people historic period 12 months through 40 years who are planning travel to an area with high or intermediate HAV endemicity and have non received HepA vaccine should receive a single dose of HepA vaccine as presently every bit travel is considered and should consummate the ii-does serial according to the routine schedule.

People with chronic liver disease every bit well as adults older than twoscore years of historic period, immunocompromised persons, and persons with other chronic medical conditions planning to depart to an surface area with high or intermediate HAV endemicity in less than 2 weeks should receive the initial dose of HepA vaccine and may likewise simultaneously exist administered IG at a separate anatomic injection site (for example in split up limbs).

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2018 to include vaccination of infants 6 through 11 months of historic period. All infants of this age traveling internationally should be given a dose of measles, mumps, rubella vaccine (MMR) before travel. Due to the potential interference of hepatitis A immune globulin (IG) with MMR vaccine effectiveness, an off-label dose of HepA vaccine is recommended instead of IG in this situation. The travel-related dose for infants 6–11 months of historic period should not exist counted toward the routine 2-dose series. The routine 2-dose HepA and MMR vaccination serial should exist initiated at historic period 12 months according to the routine, age-appropriate vaccination schedule.

Infants younger than 6 months and travelers who elect non to receive vaccine or for whom vaccine is contraindicated should receive a unmarried 0.one mL/kg dose of IG before travel when protection confronting HAV is recommended. If travel is for more than ane calendar month, a dose of 0.ii mL/kg should be administered. A 0.2 mL/kg dose can exist repeated every 2 months for travel of more than than two months duration.

Can Twinrix be used for people planning international travel?

Yes. If fourth dimension allows, utilise the standard Twinrix schedule of iii doses given intramuscularly on a 0, ane, and 6 month schedule. If travel is imminent the accelerated iv-dose Twinrix schedule can exist used, which is three doses given on days 0, 7, and 21-30 days and a booster dose at 12 months.

We take an adult patient who received the correct pediatric series of HepA vaccine as a teenager and is now traveling abroad. Does the patient need an adult booster?

No. There is no recommendation for a booster dose of HepA if a patient has completed the 2-dose series at whatsoever age.

Is information technology really necessary to vaccinate travelers to Latin America who will be staying in 4-star hotels?

Yes. Information have shown that people larn HAV infection even in such places as iv-star hotels located in Latin America.

If a traveler received the get-go dose of HepA vaccine more 1 year agone and needs to travel abroad imminently, volition the traveler need IG in improver to dose #2 prior to leaving?

No. Just give the final dose of HepA vaccine prior to travel.

If an baby younger than historic period 6 months receives IG before travel to a hepatitis A owned surface area, volition he/she need HepA vaccine before another trip to a hepatitis A endemic area?

Possibly. Since IG protects against HAV infection for but ane to ii months, depending on the dosage given, additional IG may be needed if the infant is not yet age 6 months. Once the child has reached six months of age, HepA vaccine should exist given.

Can VFC-eligible children who travel to HAV-endemic areas receive HepA vaccine under the VFC program?

Yes. ACIP recommends that all children age 1 year through 18 years should be vaccinated against hepatitis A. VFC HepA vaccine may be administered to whatever eligible child, including those recommended for vaccination at half dozen through 11 months of age as a event of travel to an HAV-endemic expanse.

If a person was born and grew upwards in a country where HAV infection is endemic (e.thou., Vietnam, Mexico) and and so moved to the The states at age 20, should that person receive HepA vaccine earlier returning to visit his/her homeland?

It depends on whether that person has a history of HAV infection. Unless there are medical records that document prior HAV infection, serologic testing for immunity (positive test for total anti-HAV) is the simply manner to determine if vaccination is necessary. For people from countries with high rates of HAV infection, such as Vietnam and Mexico, serologic testing might be done to forestall unnecessary vaccination. The toll effectiveness of serologic testing, yet, should be balanced against the possibility of delaying needed vaccination while pending exam results.

If a person has had HAV infection, should they notwithstanding receive the vaccine if planning international travel?

No, as long as there are medical records that document that the person was previously infected with HAV (i.e., positive test for total anti-HAV). If there is any doubt that the person really was infected with HAV, HepA vaccine and/or IG should exist given. The vaccine or IG will not harm a person who is already immune.

Vaccine Prophylactic Back to top

What reactions might occur subsequently administration of HepA vaccine?

No serious adverse events take been attributed definitively to HepA vaccine. Among adults, the virtually frequently reported side effects are soreness at the site of the injection and headache. In children, the nearly frequently reported side effect is soreness at the injection site. The frequency of side effects after administration of Twinrix is similar to those reported when the two single-antigen vaccines were administered.

Contraindications and Precautions Back to top

What contraindications and precautions should be followed when administering HepA vaccine?

Hepatitis A vaccine is contraindicated for people with a history of a astringent allergic reaction to a previous dose of HepA vaccine or to a vaccine component. As with all other vaccines, in that location is a precaution when giving it to anyone who is moderately or severely ill.

Can significant women receive HepA vaccine?

Yes. ACIP recommends that meaning women at risk for HAV infection during pregnancy or at risk for a severe issue from HAV infection should be vaccinated during pregnancy if non previously vaccinated. Pregnant women should be vaccinated for the same indications every bit non-meaning women. For boosted details, see folio 20 of the current ACIP recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Can lactating women receive HepA vaccine?

Yes. HepA vaccine is an inactivated vaccine and poses no impairment to the nursing infant.

Can HepA vaccine be given to immunocompromised people?

Yes. All people age 1 year or older living with HIV infection should exist vaccinated confronting hepatitis A if they have not been vaccinated, regardless of their CD4+ count.

If any immunocompromised person has a risk factor that places them at increased chance of hepatitis A (due east.g., international travel, drug use), they should be vaccinated with HepA vaccine.

I take a patient on interferon for hepatitis C, merely I desire to give him HepA vaccine. Is it okay to vaccinate him against hepatitis A while he is on interferon?

Yeah. HepA vaccine should exist given to all susceptible patients with chronic liver affliction. HepA vaccine is very immunogenic.

Vaccine Storage and Handling

How should HepA vaccine be stored?

All hepatitis A-containing vaccine should exist stored at refrigerator temperature at ii°C to eight°C (36°F to 46°F). The vaccine must not be frozen. Any vaccine exposed to freezing temperature should non be used. Do not use these or whatever other vaccines after the expiration date shown on the packaging. Whatever vaccine administered after its expiration date is not valid and should be repeated.

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Source: https://www.immunize.org/askexperts/experts_hepa.asp

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