Can Younger Hepatitis a Again if You Had It Before

Hepatitis A

Illness Issues Allowed Globulin Vaccine Recommendations Travel - International For Special Groups Vaccine Safety Administering Vaccines Contraindications and Precautions Twinrix Vaccine Storage and Handling

Disease Issues

What is hepatitis A?

Hepatitis A is a liver disease common in many parts of the world and caused past hepatitis A virus (HAV), a picornavirus that causes acute inflammation of the liver. It is non related to the common viruses that cause hepatitis B or C.

What are the signs and symptoms of hepatitis A?

Illness caused by HAV infection cannot exist distinguished from other types of astute viral hepatitis, simply it typically has an precipitous onset that can include fever, angst, anorexia, nausea, intestinal discomfort, nighttime urine, and jaundice. The likelihood of having symptoms with HAV infection is related to age. In children younger than historic period 6 years, seventy% of infections are asymptomatic. When disease does occur in immature children, it is typically non accompanied by jaundice. In older children and adults, infection typically is symptomatic, with jaundice occurring in more than 70% of patients.

Hepatitis A signs and symptoms usually resolve in 2-iii months, although x% to 15% of symptomatic people accept prolonged disease (unremarkably referred to as relapsing hepatitis A) lasting upward 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 primary means of HAV transmission. Tiptop infectivity in infected people occurs during the two week menstruum before the onset of jaundice when the concentration of virus in the stool is highest and nearly people are no longer infectious ane week later jaundice onset. Before routine vaccination of children was recommended, children were a key source of infection because well-nigh infected children had no symptoms and could shed virus in stool for weeks or months. Transmission currently occurs primarily among susceptible adults.

Common-source outbreaks and sporadic cases tin can occur from exposure to fecally-contaminated food or water. Uncooked HAV-contaminated foods have been recognized as a source of outbreaks. Cooked foods likewise tin can transmit HAV if the temperature during food preparation is inadequate to kill the virus or if food is contaminated later on cooking, every bit occurs in outbreaks associated with infected food handlers. Transmission of the virus from infected food handlers to food service institution patrons is rare, accounting for 0.2% of the almost 23,000 outbreak-associated cases of hepatitis A investigated by country health departments during 2016-2019.

Until 2017, Usa incidence rates of hepatitis A were driven past occasional outbreaks, often linked to viral contagion of imported food. Since 2017, communitywide outbreaks accept occurred more than frequently, predominantly among people who are connected by specific take chances factors, such as drug apply, and their close contacts.

What is the incubation catamenia for hepatitis A?

HAV tin can produce either asymptomatic or symptomatic infection in humans after an average incubation period of 28 days (range: 15–l days).

How is HAV shed?

In infected people, HAV replicates in the liver, is excreted in bile, and is shed in stool. Acme infectivity occurs during the 2-calendar 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 after jaundice appears, with most people no longer infectious almost a calendar week afterward jaundice appears. Children tin can shed HAV for longer periods than adults, up to 10 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 ten-fold from 2015 to 2019, with over xviii,800 cases reported to CDC in 2019. This number is an underestimate of the actual number of infections: CDC estimates that about 37,700 cases actually occurred in 2019.

Betwixt 2012 and 2015 the number of reported hepatitis A infections ranged from approximately 1200 to 1800 cases every yr. Offset in 2016, large foodborne outbreaks led to an increase in the number of cases and sustained, big person-to-person outbreaks began, primarily driven by infections amidst unvaccinated people who use drugs and people experiencing homelessness and their contacts. Since so, persistent person-to-person outbreaks take led to substantial increases in hepatitis A infection, with reported cases increasing past over l% from 2018 to 2019. More information regarding ongoing multistate outbreaks can be constitute hither: www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Practise people die from hepatitis A?

Yeah. Death as a result of fulminant hepatic failure is rare, however, older age (over 40 years) and preexisting chronic liver disease increases the gamble of severe affliction and death from hepatitis A. The person-to-person U.S. multistate outbreaks that began in 2016 have unduly affected adults with chronic liver illness and other wellness problems related to drug utilize and unstable housing. From 2016 through Nov 2021, CDC received reports of almost 43,000 cases of astute HAV infection. Of these, approximately 61% take been hospitalized and 1% (more than 400 people) have died.

Who is most at risk for acquiring HAV infection?

People who are at increased hazard for acquiring HAV infection include the post-obit:

• Travelers to countries that have loftier or intermediate endemicity of HAV infection • Men who have sex with men (MSM) • Users of injection and not-injection drugs (in other words, all who use illegal drugs) • People with occupational risk of exposure (those who piece of work with HAV-infected not-homo primates or researchers handling hepatitis A virus) • People who conceptualize shut contact with an international adoptee coming from a country with loftier 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 grouping settings for those with developmental disabilities and other settings where hygiene is difficult to maintain • People who are incarcerated

I idea people with clotting factor disorders were at risk for hepatitis A due to their regular employ of blood products. Why did ACIP decide to stop recommending routine vaccination of people with clotting factor disorders?

People with clotting cistron disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that time, the process used to make clotting factor supplements did non reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of HAV infection. Mod blood donor screening and virus reduction steps take drastically reduced that risk. In addition, more than fourscore% of people with clotting factor disorders at present receive recombinant clotting factor concentrates that are sterilized and have no adventure of HAV transmission. As a result of these factors, people with clotting factor disorders now have no greater adventure of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless it is otherwise indicated.

Are people with developmental disabilities at risk of HAV infection?

Historically, HAV infection was highly endemic in institutions for people with developmental disabilities as a outcome of poor paw hygiene, close living conditions and diaper use. Every bit fewer children accept been institutionalized and as conditions in institutions have improved, the incidence and prevalence of HAV infection have decreased, although outbreaks tin can occur in these settings. All children with developmental disabilities should receive HepA according to U.S. routine vaccine recommendations, including grab upwardly vaccination of all children through age eighteen years.

As a strategy to further reduce the risk of hepatitis A outbreaks and achieve adults in settings with a high proportion of people with risk factors for HAV infection, the current ACIP recommendations suggest considering HepA vaccination of residents and staff in facilities where hygiene is hard to maintain, such every bit group homes for people with developmental disabilities and homeless shelters.

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

No. People with chronic liver disease are not at increased run a risk for acquiring HAV infection. Notwithstanding, they are at an increased adventure 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, fatty liver disease, alcoholic liver disease, and autoimmune hepatitis.

Delight talk over the tests commonly used to diagnose hepatitis A.

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

• Anti-HAV: Total antibiotic to HAV. This diagnostic test detects total antibiotic of both IgG and IgM subclasses of HAV. If positive, it indicates either acute or resolved infection. • IgG anti-HAV: IgG antibiotic is a bracket of anti-HAV. It appears early on in the course of infection, remains detectable for the person'southward lifetime and provides lifelong protection against affliction. Its presence indicates amnesty through either HAV infection or HepA vaccination. • IgM anti-HAV: IgM antibiotic is a subclass of anti-HAV. Its presence indicates a recent infection with HAV (6 months or less). Information technology is used to diagnose acute (recently acquired) hepatitis A. Considering of the risk of fake positive IgM anti-HAV results, people should simply be tested for IgM anti-HAV if they are symptomatic and suspected of having astute hepatitis A illness. • HAV RNA tests also may be used to diagnose astute 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/affliction. To ostend a diagnosis of acute HAV infection, serologic testing for IgM anti-HAV is required. In the majority of persons, serum IgM anti-HAV becomes detectable five to x days before onset of symptoms and lasts about vi months. However, there have been reports of persons who test positive for IgM anti-HAV for up to a yr or more than following infection. An educational programme on the interpretation of hepatitis A serology is bachelor on the CDC website at www.cdc.gov/hepatitis/resources/professionals/training/serology/grooming.htm.

Can HAV exist transmitted past claret?

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

Is HAV transmitted past saliva?

In experimentally infected nonhuman primates, HAV has been detected in saliva during the incubation menses; however, transmission by human saliva has not been reported.

How common is HAV transmission in hospital 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 blood and later 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 later onset of jaundice, when they are beyond the point of top infectivity. Transmission in healthcare settings likewise has resulted from breakdowns in standard infection control practices and manual from i healthcare provider to another.

How stable is HAV in the surroundings?

Depending on atmospheric condition, HAV tin can exist stable in the surroundings for months; freezing does non inactivate (i.e., return non-infectious) HAV. HAV is inactivated past heating foods to temperatures greater than 185°F (85°C) for 1 infinitesimal. In addition, HAV on surfaces is inactivated by disinfecting surfaces with a 1:100 dilution of sodium hypochlorite (i.eastward., household bleach) in tap water.

Adequately chlorinating water through h2o treatment processes and dilution in public water systems kills HAV. Spas and swimming pools that are adequately treated are non likely to pose a risk 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. Fifty-fifty the small proportion of people who develop relapsing HAV recover afterward about six months. In one case you lot have had HAV infection and recovered, you cannot go it again.

Vaccination Recommendations Back to top

What is the best way to prevent HAV infection?

Vaccination with the full series of hepatitis A vaccine (HepA) is the best fashion to prevent HAV infection. Immune globulin (IG) besides can be used for short-term protection in sure situations.

What are the hepatitis A vaccines (HepA) that are approved for use in the United States?

Recommended dosages and schedules of hepatitis A vaccines Vaccine Historic period group Dose Volume # Doses Schedule Havrix (GSK) 1-xviii years 720 El.U.* 0.5 ml ii 0, 6-12 mos. 19 years and older 1440 El.U.* i.0 ml 2 0, six-12 mos. Vaqta (Merck & Co.) 1-18 years 25 U** 0.v ml 2 0, half-dozen-18 mos. xix years and older 50 U** 1.0 ml 2 0, 6-18 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) 18 years and older Havrix (720 El.U.) combined with Engerix-B (twenty mcg) one.0 ml 3 0, ane, half dozen mos. 4 0, 7, 21-30 days, 12 months***

*** Accelerated schedule may be used for rapid protection prior to travel or for rapid protection of an unexposed but at-chance person who as well would benefit from hepatitis B protection. Twinrix is not recommended for utilise as postal service-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

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

Where can I find information about vaccine shortages?

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

Who is recommended to receive HepA vaccine?

The Informational Committee on Immunization Practices (ACIP) recommends routine HepA vaccination for the following groups:

• All children at age ane year (12–23 months) • All children and adolescents age 2 through 18 years who take not previously received HepA should be vaccinated (i.e., routine catch-up vaccination) [2020] • People living with HIV infection [2020] • Travelers historic period 12 months and older to areas of the world with intermediate or high HAV endemicity. Low endemicity regions include the United States, Canada, Western Europe, Japan, New Zealand, and Australia. For more information, see the CDC travel health website for current data about specific countries at www.cdc.gov/travel or the CDC Yellow Book (wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-a). When in incertitude, vaccinate. • Infants age 6 through xi months traveling exterior the United States should receive 1 dose when protection confronting HAV infection is recommended. The travel dose does not count toward the routine HepA series which should be initiated at historic period ane year with the advisable dose and schedule. In these instances, the child will receive a total of three 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 state of loftier or intermediate endemicity during the beginning 60 days post-obit the adoptee's inflow in the U.South. • People who piece of work with HAV-infected nonhuman primates or with HAV in a research laboratory setting • People with chronic liver illness (including merely not limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver affliction, autoimmune hepatitis, or an ALT or AST level persistently greater than twice the upper limit of normal) • People identified during pregnancy to be at take chances for HAV infection due to presence of a specific gamble factor for exposure or at risk for severe outcome from HAV infection (for case, those with chronic liver disease or with HIV infection). • During an outbreak, whatsoever unvaccinated person who is identified as at risk for HAV infection or at risk for severe affliction from HAV • Any person who wishes to be immune to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, nutrient handlers, sewage workers, or day intendance providers because there is no evidence that their occupational risks of HAV exposure are significantly college than the general population. However, any person who desires protection from HAV infection may be vaccinated.

For details about CDC recommendations for the prevention of hepatitis A, meet the 2020 recommendations of the Advisory Committee on Immunization Practices (ACIP): world wide web.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 ii through 18 years not previously vaccinated • [added] All people age i year or older living with HIV infection • [added] People identified to be at risk for HAV infection during pregnancy • [removed] People with clotting cistron disorders

Should we give HepA to a person older than age eighteen years who requests it?

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

Which children should be routinely vaccinated against HAV infection?

All children should receive 2 doses of HepA vaccine beginning at age 1 year (i.e., 12–23 months). The two doses in the series should be administered at least half dozen months apart. Any child age ii through 18 years not previously vaccinated should exist 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 serial is at least 6 months. Is this the aforementioned every bit 24 weeks?

No. The minimum interval between dose #i and #2 of HepA vaccine is half-dozen calendar months, not 24 weeks.

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

Yep. The second dose was given more than 4 days before the minimum interval of 6 calendar months, so it is considered invalid and should exist repeated. The repeat dose should be administered the proper minimum interval (6 months) after the invalid dose. If this echo dose is inadvertently given less than 6 months after the invalid dose, it does not need to be repeated again every bit long equally the interval between the initial HepA vaccine and the most recent dose is at least vi 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 encounter the complete PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attention to Table iv on page 19 and Appendix B: Provider Guidance on Risk Cess for Hepatitis A Postexposure Prophylaxis, offset on page 36.

Salubrious people who have completed the HepA vaccination series at any time practice not need boosted PEP if they are exposed to HAV. People who take recently been exposed to HAV and who accept not received HepA vaccine previously should receive PEP as soon as possible, within 2 weeks of exposure.

People age 12 months and older exposed to HAV within the past xiv days and who have not previously completed the HepA vaccine series should receive a unmarried dose of HepA vaccine every bit before long every bit possible. In addition to vaccine, immune globulin (IG; 0.one mL/kg) may be administered to people older than age forty years depending on the providers' chance assessment. For long-term amnesty, the HepA vaccine series should be completed with a 2nd dose at to the lowest degree vi months afterwards the get-go dose. However, the 2d dose is not necessary for PEP. A second dose should not be administered sooner than six calendar months later on the starting time dose, regardless of HAV exposure risk.

People historic period 12 months or older who are immunocompromised or accept chronic liver disease, and who have been exposed to HAV within the by 14 days and have not previously completed the HepA vaccination series, should receive both IG (0.1 mL/kg) and HepA vaccine at the same visit in a different anatomic site (for example, dissever limbs) equally soon as possible after exposure. For long-term immunity, the HepA vaccination series should be completed with a second dose at least 6 months after the first dose. However, the 2nd dose is non necessary for PEP. A second dose should not be administered sooner than six calendar months later on the beginning dose, regardless of HAV exposure run a risk.

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

Twinrix contains half the amount of hepatitis A antigen every bit a standard single-dose developed HepA vaccine. Twinrix should not exist used for PEP just may be used to confer protection to at-gamble but not yet exposed persons during an outbreak.

Infants younger than historic period 12 months and persons for whom vaccine is contraindicated should receive IG (0.1 mL/kg) instead of HepA vaccine every bit soon as possible and within 2 weeks of exposure. MMR and varicella vaccines should not be administered sooner than 6 months afterwards IG administration in order to avert possible IG interference with the effectiveness of MMR and varicella vaccines.

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

Prevaccination serologic testing for HAV (measuring either total anti-HAV or IgG anti-HAV) is not indicated for children because of the depression prevalence of infection in children. It also is not routinely recommended for adults but may be considered in some settings to reduce costs associated with vaccinating people who are already immune. Prevaccination testing should not be used if information technology poses a barrier to vaccinating susceptible people, specially people who are difficult to access.

Prevaccination testing is nearly likely 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 loftier rates of previous HAV infection, vaccination history also should exist obtained, if feasible. If testing or vaccination history is non bachelor, do not postpone vaccinating. There is no harm in vaccinating a person who has had natural infection or previous doses of vaccine.

When should postvaccination testing be performed?

Serologic testing for immunity is not necessary after routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibiotic ane month or more later completing the HepA vaccination serial is recommended only for people whose time to come clinical management depends on knowing their immune condition and for whom revaccination might exist indicated, such every bit 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 not show an adequate immune response (10 mIU/mL or higher), revaccination with a complete series is recommended, followed by a second postvaccination serologic test. If that 2d test remains negative, no additional vaccination is recommended; even so, the patient should exist counseled on strategies to avoid exposure to HAV and the demand for IG if an exposure occurs. If vaccination results in seroconversion, insufficient information are available to make recommendations concerning repeat testing, booster doses or revaccination.

For Special Groups Back to top

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

ACIP recommends vaccination against HAV infection for all previously unvaccinated people who conceptualize having close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days post-obit the adoptee's arrival in the U.South. In add-on to the adoptee's new parents and siblings, this group might include grandparents, other household members, regular babysitters and other caregivers. The first dose of HepA should be given to shut contacts as soon 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 after 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 1) a person who lacks housing (regardless of whether the person is a member of a family unit), including a person whose primary residence during the night is a supervised public or individual facility (e.chiliad., shelter) that provides temporary living accommodations and a person who is a resident in transitional housing, ii) a person without permanent housing who might: live on the streets, stay in a shelter, mission, single-room occupancy facility, abandoned edifice, vehicle, or whatever other unstable or nonpermanent situation, or iii) who is "doubled upwardly", 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 members. In addition, previously homeless persons who are to exist released from a prison house or a hospital might be considered homeless if they do not accept 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 nigh initiating the HepA vaccine series in people who are homeless because we may not be able to complete the serial or keep upwards with their records over time. How much of a concern is this?

While a consummate serial of HepA is recommended for long-term protection, even a single dose of HepA vaccine has been demonstrated to provide protection against hepatitis A for more 10 years and can prevent or control outbreaks of hepatitis A. People who are experiencing homelessness may accept difficulty protecting themselves from exposure to HAV in other ways because of their living atmospheric condition. They should be vaccinated when possible and provided a record of immunization. Reporting the HepA vaccination to a state immunization information system too can facilitate immunization assessment at future healthcare encounters.

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

No. A number of studies accept shown that HCP are non at significantly increased risk of HAV infection because of their occupation. Nonetheless, if HCPs are going to work (or holiday) in a country with a high or intermediate endemic rate of HAV infection, they are at chance of HAV infection and should exist vaccinated. The only occupational indications for routine HepA vaccination are work with non-human primates or alive HAV in a laboratory setting.

Should daycare workers be routinely vaccinated against hepatitis A?

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

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

Although non at increased risk for HAV infection, people with chronic liver disease are at increased hazard for fulminant hepatitis A, hospitalization and death if they become 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 three serologic surveys conducted among United states of america wastewater workers and appropriate comparison populations, no substantial or consistent increase in the prevalence of anti-HAV was identified among wastewater workers. No piece of work-related instances of HAV transmission accept been reported among wastewater workers in the U.s.. In addition, in the United states, outbreaks of hepatitis A caused by flooding, which can behave raw sewage, have not been reported.

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

People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that time, the process used to make clotting factor supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of HAV infection. Modern claret donor screening and virus reduction steps have drastically reduced that risk. In addition, more than lxxx% of people with clotting cistron disorders at present receive recombinant clotting factor concentrates that are sterilized and have no risk of HAV manual. As a event of these factors, people with clotting factor disorders at present accept no greater gamble of hepatitis A than the full general population and are no longer recommended to receive HepA vaccine unless it is otherwise indicated.

Why is hepatitis A vaccination recommended (and IG non recommended) for babe travelers historic period half-dozen through 11 months at chance 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 6 through eleven months who travel internationally are recommended to receive a dose of measles, mumps, and rubella vaccine (MMR) to reduce the risk of measles infection during travel.

The antibodies in immune globulin (IG) typically used to foreclose HAV infection in infants before the first birthday can interfere with the effectiveness of MMR vaccine. An infant who is given IG should not exist vaccinated with MMR or varicella vaccines for at to the lowest degree 6 months after IG administration. If an baby age 6 through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-label apply of HepA vaccine (not IG) in addition to MMR. The HepA and MMR doses administered before the commencement birthday do not count toward the routine vaccination serial of either vaccine: these infant travelers will nonetheless need two doses of HepA and two doses of MMR when age advisable.

Can pregnant women receive hepatitis A vaccine?

Yes. The ACIP recommends that pregnant women at risk for HAV infection during pregnancy or at risk for a severe issue from HAV infection should exist vaccinated during pregnancy if non previously vaccinated. Significant women should be vaccinated for the same indications as non-pregnant women. For additional information, see folio 20 of the recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Administering Vaccines Dorsum to acme

By 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 determined past the patient's historic period and body mass.

Can HepA vaccine be given concurrently with other vaccines?

Yes. Other inactivated and/or live virus vaccines can be administered at the same time as HepA vaccine, but should be given at a dissimilar anatomical site, if possible. If given in the same muscle, separate the injections by a minimum distance of 1 inch.

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

Yes, VFC-supported HepA vaccine is available for children 12 months through 18 years who are VFC-eligible. In addition, combination HepA and HepB vaccine (Twinrix; GSK) is also available for people who are age 18 years who are VFC-eligible.

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

Y'all do not demand to offset the series over over again. The immunogenicity of one dose of HepA vaccine is 94% to 100%; studies have shown persistent protection from a unmarried dose lasting more than than ten years. To ensure optimal long-term protection it is important to administer the second dose.

To complete a 21-twelvemonth-old patient'due south HepA vaccine series, 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 advisable for their age at the time of administration. You should give the patient one adult dose of HepA to complete the 2-dose series. It is not necessary to restart the vaccine series.

One of our staff gave a dose of pediatric HepA vaccine to an adult patient by fault. How do we remedy this error?

In general, if the fault is discovered on the same clinic twenty-four hours, you tin administer the other "half" of the dose on that same day. If the error is discovered after, the dose should not be counted, and then the person should exist recalled to the office and given a full age-appropriate repeat dose.

If you requite more than an historic period-appropriate dose (for example, an adult dose of HepA vaccine given to a child), count the dose as valid and notify the patient/parent about the error. There may be an increased chance 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 need for a 2d dose.

Avoid such errors by checking the vaccine vial label iii times.

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

The efficacy information from the clinical trials were based on age at time of vaccination, and not on the weight of the individual. Hence, the dosage recommendations reflect this historic period-based efficacy data. The same holds truthful for HepB vaccine. In addition, college response rates are expected in younger people, fifty-fifty 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 two 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 xx mcg of hepatitis B antigen (the full Engerix-B adult dose).

In the U.Due south., Twinrix is licensed for use in people who are age 18 years or older. It can be administered to people who are at hazard for both hepatitis A and hepatitis B, such equally certain international travelers, people with HIV infection, people with chronic liver illness not caused by hepatitis B, men who accept sex with men, illegal drug users, or to people who simply want to be allowed to both diseases. Primary immunization consists of 3 doses given intramuscularly on a 0, 1, and 6 calendar month schedule. In 2007, the FDA also approved a iv-dose schedule for Twinrix. Information technology consists of 3 doses given within 4 weeks, followed by a booster dose at 12 months (0, vii days, 21–xxx days, and 12 months). The 4-dose schedule could do good individuals needing rapid protection from hepatitis A and hepatitis B, such every bit people traveling to high-prevalence areas imminently.

Twinrix cannot be used for postexposure prophylaxis.

I have seen adults who take had 1 or 2 doses of Twinrix, simply nosotros only bear unmarried-antigen vaccine in our practice. How should we complete their vaccination serial with single-antigen vaccines?

Twinrix is licensed as a 3-dose series for people age 18 years and older. If Twinrix is not available or if you cull non to use Twinrix to complete the Twinrix series, you should practise the following: If 1 dose of Twinrix was given, consummate the serial with 2 developed doses of hepatitis B vaccine and 2 adult doses of hepatitis A vaccine. If two doses of Twinrix were given, complete the schedule with 1 developed dose of hepatitis A vaccine and 1 developed dose of hepatitis B vaccine.

Another way 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 tin be substituted for any dose of the hepatitis B series but non for any dose of the hepatitis A serial.

• Whatsoever combination of 3 doses of adult hepatitis B or three doses of Twinrix is a complete series of hepatitis B vaccine. • One dose of Twinrix + ii doses of developed hepatitis A is a complete serial of hepatitis A vaccine. • Ii doses of Twinrix + 1 dose of adult hepatitis A is a complete series of hepatitis A vaccine.

Nosotros're thinking of using Twinrix and we're wondering whether nosotros can use it for doses #1 and #3 only and utilise single antigen hepatitis B vaccine for dose #2?

No. Twinrix contains l% less hepatitis A antigen component than Havrix, GSK's monovalent hepatitis A vaccine [720 vs. 1440 El. U.], so the patient would not receive the recommended dose of hepatitis A vaccine antigen. For this reason, 3 doses of Twinrix must incorporate the series.

Immune Globulin Dorsum to top

What is immune globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile preparation of full-bodied antibodies (i.due east., immunoglobulins) made from pooled human plasma candy by cold ethanol fractionation. GamaSTAN is the simply IG product licensed in the Us for the prevention of hepatitis A. Only plasma that has tested negative for hepatitis B surface antigen, antibiotic to homo immunodeficiency virus (HIV), and antibody to hepatitis C virus (HCV) is used to produce IG. In addition, the Food and Drug Assistants requires that the procedure used to produce IG include a viral inactivation step or that concluding products test negative for HCV-RNA by polymerase concatenation reaction. Anti-HAV concentrations differ amidst IG lots and decreasing concentrations have been observed over the past 30 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 reverberate this modify in anti-HAV authorisation.

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 one to 2 months.

When administered for preexposure prophylaxis, a dose of 0.1 mL/kg will provide protection for up to 1 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. There is no maximum number of times the bimonthly doses of IG may be repeated as long as hepatitis A prophylaxis is required.

For postexposure prophylaxis, the recommended dosage is 0.one 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 musculus of the upper arm. Exercise non use the gluteal region as an injection site because of the hazard of injury to the sciatic nervus.

Does IG cause adverse events?

Serious adverse events from GamaSTAN IG are rare. Anaphylaxis has been reported after repeated assistants to people with known immunoglobulin A (IgA) deficiency; thus, IG should not be administered to these people. IG products including GamaSTAN accept been associated with the germination of blood clots (thrombosis) later on administration, especially if the patient has other risk factors for thrombosis. Patients should exist counseled almost this run a risk.

Can pregnant or lactating women receive IG?

Yes. Pregnancy or lactation is non a contraindication to IG administration if clearly needed.

A kid in my practice was given hepatitis A IG (GamaSTAN, Grifols) when she was 10 months former after her mother tested positive for hepatitis A. She'southward scheduled for her 12-month-old well-kid visit. Will this affect her vaccination schedule?

Aye. IG may be given any time before or subsequently inactivated vaccines. However, 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 appointment of IG administration before administering MMR and varicella vaccines.

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

Please see details of the recommendations for the use of IG for the prevention of hepatitis A provided in Table 4 (page 19) 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 brief 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 2 weeks of departure may consider IG in addition to vaccination, based upon the clinician's risk assessment • 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 assessment • Previously unvaccinated people who are over age xl years and vaccinated within 2 weeks of departure may consider IG in addition to vaccination, based upon the clinician's risk assessment

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

• Infants nether historic period 12 months • Previously unvaccinated immunocompromised adults (including HIV+), in improver to vaccination • Previously unvaccinated adults with chronic liver disease, in add-on to vaccination • Previously unvaccinated adults over age 40 years, consider IG in addition to vaccination, based upon clinician take chances assessment • People with HIV infection, previously vaccinated, consider IG post-obit a high-take chances exposure (household or sexual contact), based upon clinician gamble assessment

Travel - International Back to top

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people age 6 months or older who are traveling to or working in an expanse of the world at intermediate or loftier take a chance of hepatitis A transmission. Areas of low risk include the U.s.a., Canada, Japan, New Zealand, Australia and Western Europe. Visit the CDC's Traveler Health website for more than information well-nigh specific destinations and current outbreaks or travel notices (https://wwwnc.cdc.gov/travel/). When in doubt, 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 page 35 of the current ACIP recommendations for the prevention of hepatitis A: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Healthy people age 12 months through twoscore years who are planning travel to an area with high or intermediate HAV endemicity and take non received HepA vaccine should receive a unmarried dose of HepA vaccine equally shortly every bit travel is considered and should complete the 2-does series according to the routine schedule.

People with chronic liver affliction too as adults older than forty years of historic period, immunocompromised persons, and persons with other chronic medical conditions planning to depart to an area with high or intermediate HAV endemicity in less than 2 weeks should receive the initial dose of HepA vaccine and may also simultaneously exist administered IG at a separate anatomic injection site (for example in split 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 historic period 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-characterization dose of HepA vaccine is recommended instead of IG in this state of affairs. The travel-related dose for infants 6–11 months of age should not be counted toward the routine 2-dose series. The routine 2-dose HepA and MMR vaccination series should be initiated at age 12 months according to the routine, age-appropriate vaccination schedule.

Infants younger than 6 months and travelers who elect not to receive vaccine or for whom vaccine is contraindicated should receive a unmarried 0.1 mL/kg dose of IG before travel when protection against HAV is recommended. If travel is for more than one month, a dose of 0.two mL/kg should exist administered. A 0.2 mL/kg dose tin can be repeated every ii months for travel of more than than 2 months duration.

Can Twinrix exist used for people planning international travel?

Yes. If fourth dimension allows, use the standard Twinrix schedule of 3 doses given intramuscularly on a 0, 1, and 6 month schedule. If travel is imminent the accelerated 4-dose Twinrix schedule can be used, which is iii doses given on days 0, vii, and 21-30 days and a booster dose at 12 months.

We have an adult patient who received the right pediatric serial of HepA vaccine as a teenager and is now traveling away. Does the patient demand an adult booster?

No. At that place is no recommendation for a booster dose of HepA if a patient has completed the two-dose series at any historic period.

Is it really necessary to vaccinate travelers to Latin America who will exist staying in 4-star hotels?

Yep. Data accept shown that people acquire HAV infection even in such places as 4-star hotels located in Latin America.

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

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

If an infant younger than age 6 months receives IG before travel to a hepatitis A owned area, will he/she need HepA vaccine earlier another trip to a hepatitis A endemic area?

Possibly. Since IG protects against HAV infection for only one to 2 months, depending on the dosage given, additional IG may be needed if the infant is non nonetheless age half-dozen months. Once the kid has reached six months of age, HepA vaccine should be given.

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

Yes. ACIP recommends that all children historic period i year through 18 years should be vaccinated against hepatitis A. VFC HepA vaccine may be administered to any eligible kid, including those recommended for vaccination at 6 through eleven months of age as a result of travel to an HAV-endemic expanse.

If a person was born and grew upward in a state where HAV infection is endemic (e.g., Vietnam, Mexico) so moved to the United 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 amnesty (positive test for total anti-HAV) is the only way to decide 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 prevent unnecessary vaccination. The toll effectiveness of serologic testing, however, should be counterbalanced against the possibility of delaying needed vaccination while awaiting test results.

If a person has had HAV infection, should they still 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 actually 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 after assistants of HepA vaccine?

No serious adverse events have been attributed definitively to HepA vaccine. Among adults, the most often reported side furnishings are soreness at the site of the injection and headache. In children, the almost 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 Dorsum to acme

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

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

Tin meaning women receive HepA vaccine?

Yes. ACIP recommends that significant women at risk for HAV infection during pregnancy or at take a chance for a severe outcome from HAV infection should exist vaccinated during pregnancy if not previously vaccinated. Pregnant women should exist vaccinated for the same indications as non-pregnant women. For additional details, run across folio twenty of the current ACIP recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Tin can lactating women receive HepA vaccine?

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

Tin HepA vaccine be given to immunocompromised people?

Aye. All people age 1 year or older living with HIV infection should be vaccinated against hepatitis A if they take not been vaccinated, regardless of their CD4+ count.

If whatever immunocompromised person has a risk factor that places them at increased risk of hepatitis A (e.1000., international travel, drug employ), they should be vaccinated with HepA vaccine.

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

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

Vaccine Storage and Handling

How should HepA vaccine exist stored?

All hepatitis A-containing vaccine should exist stored at refrigerator temperature at 2°C to 8°C (36°F to 46°F). The vaccine must not be frozen. Any vaccine exposed to freezing temperature should not be used. Do not use these or any other vaccines after the expiration engagement shown on the packaging. Any vaccine administered later its expiration appointment is not valid and should be repeated.

Dorsum to tiptop

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

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