When Should I Get the Hepatitis a Vaccines Again

Hepatitis A

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Disease Bug

What is hepatitis A?

Hepatitis A is a liver disease common in many parts of the world and acquired past hepatitis A virus (HAV), a picornavirus that causes astute inflammation of the liver. It is not related to the mutual viruses that cause hepatitis B or C.

What are the signs and symptoms of hepatitis A?

Disease caused by HAV infection cannot be distinguished from other types of acute viral hepatitis, merely it typically has an abrupt onset that can include fever, malaise, anorexia, nausea, abdominal discomfort, dark urine, and jaundice. The likelihood of having symptoms with HAV infection is related to age. In children younger than age 6 years, seventy% of infections are asymptomatic. When illness does occur in young 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 2-3 months, although 10% to 15% of symptomatic people accept prolonged illness (commonly referred to equally relapsing hepatitis A) lasting upwards to 6 months and should exist considered infectious during that time.

How is HAV transmitted?

Person-to-person spread through the fecal-oral route is the primary means of HAV manual. Peak infectivity in infected people occurs during the two week period before the onset of jaundice when the concentration of virus in the stool is highest and most people are no longer infectious one week after jaundice onset. Before routine vaccination of children was recommended, children were a key source of infection because nigh infected children had no symptoms and could shed virus in stool for weeks or months. Manual currently occurs primarily amid susceptible adults.

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

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

What is the incubation period for hepatitis A?

HAV can produce either asymptomatic or symptomatic infection in humans after an average incubation menstruation of 28 days (range: fifteen–fifty 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 2-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 afterwards jaundice appears, with near people no longer infectious nigh a week afterwards jaundice appears. Children can shed HAV for longer periods than adults, up to ten weeks or longer afterward onset of clinical illness.

How mutual is HAV infection in the United States?

The incidence of hepatitis A in the US increased more than x-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 about 37,700 cases really 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, big person-to-person outbreaks began, primarily driven by infections amid unvaccinated people who apply drugs and people experiencing homelessness and their contacts. Since and 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 information regarding ongoing multistate outbreaks can exist plant hither: www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Exercise people die from hepatitis A?

Yes. Death as a result of fulminant hepatic failure is rare, however, older age (over 40 years) and preexisting chronic liver illness increases the risk of severe disease and expiry from hepatitis A. The person-to-person U.S. multistate outbreaks that began in 2016 have disproportionately affected adults with chronic liver disease and other health issues related to drug use and unstable housing. From 2016 through Nov 2021, CDC received reports of almost 43,000 cases of astute HAV infection. Of these, approximately 61% have been hospitalized and 1% (more than than 400 people) have 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 sexual activity with men (MSM) • Users of injection and non-injection drugs (in other words, all who use illegal drugs) • People with occupational risk of exposure (those who work with HAV-infected non-human primates or researchers handling hepatitis A virus) • People who anticipate close contact with an international adoptee coming from a country 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 factor disorders were at hazard for hepatitis A due to their regular employ of blood products. Why did ACIP make up one's mind to stop recommending routine vaccination of people with clotting factor 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 cistron supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased hazard of HAV infection. Modern blood donor screening and virus reduction steps have drastically reduced that chance. In addition, more than lxxx% of people with clotting factor disorders at present receive recombinant clotting factor concentrates that are sterilized and accept no risk of HAV transmission. As a outcome of these factors, people with clotting cistron disorders now accept no greater adventure of hepatitis A than the full general population and are no longer recommended to receive HepA vaccine unless it is otherwise indicated.

Are people with developmental disabilities at run a risk of HAV infection?

Historically, HAV infection was highly endemic in institutions for people with developmental disabilities as a result of poor hand hygiene, shut living conditions and diaper use. Equally fewer children have 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.South. routine vaccine recommendations, including catch upward vaccination of all children through age 18 years.

As a strategy to further reduce the take chances of hepatitis A outbreaks and reach 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 difficult to maintain, such as group homes for people with developmental disabilities and homeless shelters.

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

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

Please hash out 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: Full antibiotic to HAV. This diagnostic examination detects total 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 subclass of anti-HAV. Information technology appears early on in the course of infection, remains detectable for the person's lifetime and provides lifelong protection against disease. Its presence indicates amnesty through either HAV infection or HepA vaccination. • IgM anti-HAV: IgM antibody is a subclass of anti-HAV. Its presence indicates a recent infection with HAV (half-dozen months or less). It is used to diagnose astute (recently acquired) hepatitis A. Because of the risk of simulated positive IgM anti-HAV results, people should only be tested for IgM anti-HAV if they are symptomatic and suspected of having acute hepatitis A illness. • HAV RNA tests besides 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 course of infection, remains detectable for the person's lifetime and indicates lifelong protection confronting the infection/disease. 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 5 to ten days before onset of symptoms and lasts about 6 months. Yet, there accept been reports of persons who examination positive for IgM anti-HAV for upward to a year or more following infection. An educational plan on the interpretation of hepatitis A serology is available on the CDC website at www.cdc.gov/hepatitis/resources/professionals/grooming/serology/training.htm.

Can HAV exist transmitted past blood?

Yep. 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.eastward., when HAV is in the donor'south blood). Since 2002, tests to notice the presence of hepatitis A virus RNA in donated plasma take drastically reduced the risk of hepatitis A transmission from products derived from blood plasma.

Is HAV transmitted past saliva?

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

How common is HAV transmission in hospital settings?

Infirmary-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 afterward transmitted HAV to other infants and staff. Outbreaks of hepatitis A caused past transmission from developed patients to healthcare personnel (HCP) are typically associated with fecal incontinence and inadequate hand hygiene, although the majority of hospitalized patients who take hepatitis A are admitted after onset of jaundice, when they are beyond the point of tiptop infectivity. Transmission in healthcare settings also has resulted from breakdowns in standard infection control practices and manual from one healthcare provider to some other.

How stable is HAV in the surroundings?

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

Adequately chlorinating h2o through water handling processes and dilution in public water systems kills HAV. Spas and swimming pools that are adequately treated are not probable 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. Even the small proportion of people who develop relapsing HAV recover subsequently well-nigh 6 months. Once you have had HAV infection and recovered, you cannot get it again.

Vaccination Recommendations Dorsum to pinnacle

What is the best way to prevent HAV infection?

Vaccination with the total serial of hepatitis A vaccine (HepA) is the best way to forbid HAV infection. Immune globulin (IG) as well can exist used for short-term protection in certain 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 Age group Dose Volume # Doses Schedule Havrix (GSK) 1-xviii years 720 El.U.* 0.5 ml 2 0, 6-12 mos. xix years and older 1440 El.U.* one.0 ml 2 0, 6-12 mos. Vaqta (Merck & Co.) 1-18 years 25 U** 0.5 ml 2 0, 6-18 mos. 19 years and older 50 U** 1.0 ml 2 0, half-dozen-eighteen mos.

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

Combination vaccine using hepatitis A and hepatitis B vaccines Vaccine Age group Antigens used Book # Doses Schedule Twinrix (GSK) 18 years and older Havrix (720 El.U.) combined with Engerix-B (20 mcg) 1.0 ml 3 0, ane, 6 mos. iv 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-risk person who also would benefit from hepatitis B protection. Twinrix is not recommended for utilise as post-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

Aye, a number of studies indicate that the 2 brands of HepA, Havrix (GSK) and Vaqta (Merck), are interchangeable.

Where tin can I find information near vaccine shortages?

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

Who is recommended to receive HepA vaccine?

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

• All children at age one year (12–23 months) • All children and adolescents historic period two through 18 years who have non previously received HepA should exist vaccinated (i.due east., routine grab-upward vaccination) [2020] • People living with HIV infection [2020] • Travelers age 12 months and older to areas of the world with intermediate or high HAV endemicity. Depression 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 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 uncertainty, vaccinate. • Infants age 6 through 11 months traveling outside the The states should receive one dose when protection against HAV infection is recommended. The travel dose does non count toward the routine HepA series which should exist initiated at historic period i year with the appropriate dose and schedule. In these instances, the child volition receive a total of 3 doses of HepA vaccine. • Men who have sex activity with men • Users of illegal drugs, injectable or noninjectable • People who are homeless or in unstable living arrangements, including shelters • Previously unvaccinated people who conceptualize having close personal contact with an international adoptee from a country of high or intermediate endemicity during the starting time 60 days post-obit the adoptee'south inflow 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 affliction (including but non limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fat 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 exist at risk for HAV infection due to presence of a specific gamble factor for exposure or at hazard for severe outcome from HAV infection (for example, those with chronic liver disease or with HIV infection). • During an outbreak, any unvaccinated person who is identified every bit at risk for HAV infection or at adventure for severe affliction from HAV • Whatsoever person who wishes to exist immune to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, food handlers, sewage workers, or day intendance providers because there is no evidence that their occupational risks of HAV exposure are significantly higher than the full 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, see 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 18 years not previously vaccinated • [added] All people age 1 yr 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 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 whatever 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 historic period 1 year (i.due east., 12–23 months). The ii doses in the series should be administered at least 6 months apart. Any child age 2 through 18 years non previously vaccinated should be vaccinated. For a copy of the ACIP recommendations on hepatitis A, become to www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

For hepatitis A vaccination, the minimum interval between the ii-dose series is at least 6 months. Is this the same equally 24 weeks?

No. The minimum interval between dose #1 and #2 of HepA vaccine is six calendar months, not 24 weeks.

I have a child who was given her 2d dose of hepatitis A vaccine 4 months after the start dose. Does it need to be repeated, and if and then, when?

Aye. The 2nd dose was given more 4 days before the minimum interval of 6 agenda months, so information technology is considered invalid and should be repeated. The repeat dose should be administered the proper minimum interval (6 months) after the invalid dose. If this repeat dose is inadvertently given less than half dozen months afterward the invalid dose, it does not need to exist repeated again as long equally the interval betwixt the initial HepA vaccine and the most contempo dose is at least half-dozen 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). Delight see the complete PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attending to Tabular array 4 on page xix and Appendix B: Provider Guidance on Risk Cess for Hepatitis A Postexposure Prophylaxis, beginning on page 36.

Healthy people who have completed the HepA vaccination series at any fourth dimension do not need additional PEP if they are exposed to HAV. People who accept recently been exposed to HAV and who have not received HepA vaccine previously should receive PEP every bit shortly every bit possible, within 2 weeks of exposure.

People age 12 months and older exposed to HAV within the by 14 days and who have non previously completed the HepA vaccine series should receive a single dose of HepA vaccine as soon as possible. In addition to vaccine, immune globulin (IG; 0.1 mL/kg) may be administered to people older than age 40 years depending on the providers' run a risk assessment. For long-term immunity, the HepA vaccine series should be completed with a second dose at to the lowest degree vi months after the kickoff dose. All the same, the second dose is not necessary for PEP. A second dose should not exist administered sooner than 6 calendar months after the kickoff dose, regardless of HAV exposure chance.

People age 12 months or older who are immunocompromised or take chronic liver disease, and who accept been exposed to HAV inside the by 14 days and accept non 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 instance, separate limbs) as presently as possible later exposure. For long-term amnesty, the HepA vaccination series should be completed with a second dose at least half dozen months after the first dose. However, the 2nd dose is not necessary for PEP. A second dose should not be administered sooner than 6 calendar months after the first dose, regardless of HAV exposure risk.

People with HIV infection develop protective levels of antibiotic more slowly and are less probable to develop protective antibody levels after 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 be administered if the exposed private is not fully vaccinated; however, CDC also advises clinicians to consider administering IG PEP to an private with HIV subsequently a high-take chances exposure (such equally a household or sexual contact) fifty-fifty if the individual has been fully vaccinated.

Twinrix contains half the amount of hepatitis A antigen equally a standard single-dose adult HepA vaccine. Twinrix should not be used for PEP but may be used to confer protection to at-risk but not yet exposed persons during an outbreak.

Infants younger than age 12 months and persons for whom vaccine is contraindicated should receive IG (0.1 mL/kg) instead of HepA vaccine as soon as possible and within 2 weeks of exposure. MMR and varicella vaccines should not exist administered sooner than half dozen months after IG assistants 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 considering of the low prevalence of infection in children. Information technology also is not routinely recommended for adults but may be 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, specially people who are difficult to access.

Prevaccination testing is about probable to be cost-effective for adults who were either born in or lived for long periods of fourth dimension in areas of the world with loftier 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 available, exercise 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 amnesty is not necessary subsequently routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibody one month or more afterward completing the HepA vaccination series is recommended only for people whose time to come clinical direction depends on knowing their immune condition and for whom revaccination might exist indicated, such equally 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 show an adequate allowed 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 boosted vaccination is recommended; however, the patient should be counseled on strategies to avert exposure to HAV and the need for IG if an exposure occurs. If vaccination results in seroconversion, bereft data are available to make recommendations concerning repeat testing, booster doses or revaccination.

For Special Groups Dorsum to peak

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

ACIP recommends vaccination against HAV infection for all previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of loftier or intermediate endemicity during the first threescore days following the adoptee's arrival in the U.S. In improver to the adoptee's new parents and siblings, this group might include grandparents, other household members, regular babysitters and other caregivers. The starting time dose of HepA should be given to close contacts as before long every bit adoption is planned, ideally at least 2 weeks earlier the arrival of the adoptee. A second 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 lot provide a definition of "experiencing homelessness"?

The 2020 ACIP recommendations for the prevention of hepatitis A define a person experiencing homelessness as 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 nighttime is a supervised public or private facility (e.chiliad., shelter) that provides temporary living accommodations and a person who is a resident in transitional housing, two) a person without permanent housing who might: alive on the streets, stay in a shelter, mission, single-room occupancy facility, abandoned edifice, vehicle, or whatever other unstable or nonpermanent situation, or 3) who is "doubled upwards", 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 improver, previously homeless persons who are to be released from a prison house or a hospital might be considered homeless if they do not have a stable housing situation to which they can render. The instability of a person's living arrangements is critical to the definition of homelessness.

Some people on my team are worried virtually initiating the HepA vaccine serial in people who are homeless because we may not be able to consummate the serial or keep upwardly with their records over time. How much of a concern is this?

While a complete series of HepA is recommended for long-term protection, even a unmarried dose of HepA vaccine has been demonstrated to provide protection confronting 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 considering 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 data organisation likewise tin facilitate immunization cess at future healthcare encounters.

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

No. A number of studies take shown that HCP are not at significantly increased take chances of HAV infection considering of their occupation. Notwithstanding, if HCPs are going to work (or vacation) in a country with a high or intermediate endemic rate of HAV infection, they are at run a risk of HAV infection and should exist vaccinated. The only occupational indications for routine HepA vaccination are piece of work with non-man primates or live HAV in a laboratory setting.

Should daycare workers be routinely vaccinated against hepatitis A?

No. In the past, outbreaks of hepatitis A occurred amidst children in child care centers, infecting employees of those centers, especially those caring for infants and toddlers. Following widespread adoption of early childhood vaccination confronting 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 risk for HAV infection, people with chronic liver disease are at increased risk for fulminant hepatitis A, hospitalization and death if they go 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 product disposal workers?

In published reports of three serologic surveys conducted amid United States wastewater workers and appropriate comparison populations, no substantial or consistent increase in the prevalence of anti-HAV was identified amid wastewater workers. No work-related instances of HAV transmission take been reported amid wastewater workers in the The states. In addition, in the U.s., outbreaks of hepatitis A acquired past flooding, which can carry raw sewage, take not been reported.

Why is hepatitis A vaccination no longer recommended for people with clotting gene 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. Modern blood donor screening and virus reduction steps accept drastically reduced that risk. In add-on, more than than fourscore% of people with clotting factor disorders now receive recombinant clotting factor concentrates that are sterilized and have no chance of HAV manual. Every bit a result of these factors, people with clotting factor disorders now have no greater take a chance of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless it is otherwise indicated.

Why is hepatitis A vaccination recommended (and IG not recommended) for infant travelers age 6 through 11 months at risk of exposure to HAV?

Because of measles. Measles is highly communicable and poses a serious threat to the wellness of unvaccinated infants. For this reason, all infants age 6 through 11 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 allowed globulin (IG) typically used to prevent HAV infection in infants before the showtime birthday tin interfere with the effectiveness of MMR vaccine. An infant who is given IG should not exist vaccinated with MMR or varicella vaccines for at least half dozen months afterward IG assistants. If an infant age six through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-label employ of HepA vaccine (not IG) in addition to MMR. The HepA and MMR doses administered before the first birthday do not count toward the routine vaccination serial of either vaccine: these infant travelers will still demand two doses of HepA and 2 doses of MMR when age appropriate.

Tin pregnant women receive hepatitis A vaccine?

Aye. The ACIP recommends that pregnant women at risk for HAV infection during pregnancy or at risk for a astringent issue from HAV infection should exist vaccinated during pregnancy if not previously vaccinated. Pregnant women should be vaccinated for the same indications as not-pregnant women. For additional information, see page 20 of the recommendations: world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Administering Vaccines Back to peak

By what method should hepatitis A vaccine be administered?

Hepatitis A vaccine (HepA) should be administered intramuscularly (IM), using the advisable injection site and needle size as adamant by the patient'southward age and body mass.

Can HepA vaccine be given concurrently with other vaccines?

Aye. Other inactivated and/or alive virus vaccines can be administered at the same time every bit HepA vaccine, but should be given at a dissimilar anatomical site, if possible. If given in the same musculus, separate the injections by a minimum distance of ane inch.

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

Yes, VFC-supported HepA vaccine is available for children 12 months through 18 years who are VFC-eligible. In improver, 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?

Yous practice not demand to kickoff the series over again. The immunogenicity of 1 dose of HepA vaccine is 94% to 100%; studies have shown persistent protection from a single dose lasting more than 10 years. To ensure optimal long-term protection information technology is important to administer the second dose.

To complete a 21-year-onetime patient'due south HepA vaccine series, how many adult doses should I give if the patient received a unmarried dose of pediatric HepA vaccine 5 years agone?

A person should receive the dosage of HepA vaccine advisable for their age at the time of administration. You lot should give the patient one adult dose of HepA to complete the 2-dose series. Information technology is non necessary to restart the vaccine serial.

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

In general, if the error is discovered on the aforementioned clinic day, you can administer the other "half" of the dose on that same day. If the error is discovered later on, the dose should not be counted, and so the person should exist recalled to the role and given a full age-appropriate echo dose.

If you lot give more than an age-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 exist an increased risk of a local adverse reaction when more 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 3 times.

Why does a fifteen year old who weighs 160 pounds receive a pediatric dose of HepA while his 110-pound female parent receives an developed 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 age-based efficacy information. The aforementioned holds true for HepB vaccine. In add-on, higher response rates are expected in younger people, fifty-fifty if their weights are to a higher place the norm.

Could yous please provide more data near Twinrix (the combination hepatitis A and B vaccine) and the 2 schedules for its utilise?

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 developed dose) and 20 mcg of hepatitis B antigen (the total Engerix-B adult dose).

In the U.S., Twinrix is licensed for apply in people who are age 18 years or older. It can be administered to people who are at adventure for both hepatitis A and hepatitis B, such as certain international travelers, people with HIV infection, people with chronic liver disease not acquired past hepatitis B, men who have sexual activity with men, illegal drug users, or to people who simply want to exist immune to both diseases. Main immunization consists of iii doses given intramuscularly on a 0, 1, and 6 month schedule. In 2007, the FDA also approved a 4-dose schedule for Twinrix. It consists of iii doses given inside 4 weeks, followed past a booster dose at 12 months (0, 7 days, 21–thirty days, and 12 months). The iv-dose schedule could benefit individuals needing rapid protection from hepatitis A and hepatitis B, such as people traveling to high-prevalence areas imminently.

Twinrix cannot be used for postexposure prophylaxis.

I have seen adults who have had i or 2 doses of Twinrix, but we only behave unmarried-antigen vaccine in our practise. How should we complete their vaccination series with single-antigen vaccines?

Twinrix is licensed every bit a 3-dose series for people historic period 18 years and older. If Twinrix is not available or if you choose not to use Twinrix to complete the Twinrix series, you should do the following: If i dose of Twinrix was given, complete the series with 2 developed doses of hepatitis B vaccine and ii 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.

Some other fashion 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 any dose of the hepatitis B serial but not for any dose of the hepatitis A series.

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

We're thinking of using Twinrix and nosotros're wondering whether we tin can use it for doses #one and #3 merely and use single antigen hepatitis B vaccine for dose #two?

No. Twinrix contains 50% 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 comprise the series.

Immune Globulin Back to top

What is allowed globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile preparation of concentrated antibodies (i.e., immunoglobulins) fabricated from pooled human plasma candy by cold ethanol fractionation. GamaSTAN is the only IG product licensed in the United States for the prevention of hepatitis A. Only plasma that has tested negative for hepatitis B surface antigen, antibody to homo immunodeficiency virus (HIV), and antibiotic to hepatitis C virus (HCV) is used to produce IG. In add-on, the Nutrient 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 concatenation reaction. Anti-HAV concentrations differ among IG lots and decreasing concentrations take been observed over the past thirty years, probably because 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 change in anti-HAV potency.

How does immune globulin (IG) piece of work?

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

When administered for preexposure prophylaxis, a dose of 0.ane mL/kg will provide protection for upward to one month and a dose of 0.2 mL/kg volition provide protection for up to 2 months. If longer term protection is required and vaccination is contraindicated, a dose of 0.2 mL/kg tin 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 0.1 mL/kg.

How is IG packaged and how is IG administered?

Intramuscular IG is available in unmarried-use vials (2 mL and x mL). It should be administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Do not use the gluteal region as an injection site because of the adventure 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 administration to people with known immunoglobulin A (IgA) deficiency; thus, IG should not be administered to these people. IG products including GamaSTAN have been associated with the formation of blood clots (thrombosis) afterwards administration, specially if the patient has other chance factors for thrombosis. Patients should be counseled about this risk.

Can significant or lactating women receive IG?

Yes. Pregnancy or lactation is not a contraindication to IG assistants if clearly needed.

A child in my practice was given hepatitis A IG (GamaSTAN, Grifols) when she was ten months sometime after her mother tested positive for hepatitis A. She'due south scheduled for her 12-month-old well-child visit. Will this touch her vaccination schedule?

Yes. IG may be given whatsoever time earlier or later on inactivated vaccines. However, the antibodies in IG may interfere with the effectiveness of certain alive-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 earlier administering MMR and varicella vaccines.

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

Please come across details of the recommendations for the use of IG for the prevention of hepatitis A provided in Tabular array 4 (page xix) 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 six months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver disease vaccinated within 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 improver to vaccination, regardless of the timing of vaccination, based upon the clinician'southward risk assessment • Previously unvaccinated people who are over age xl years and vaccinated within 2 weeks of departure may consider IG in improver to vaccination, based upon the clinician's risk assessment

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

• Infants under age 12 months • Previously unvaccinated immunocompromised adults (including HIV+), in improver to vaccination • Previously unvaccinated adults with chronic liver disease, in addition to vaccination • Previously unvaccinated adults over age 40 years, consider IG in improver 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 Back to pinnacle

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people age half dozen months or older who are traveling to or working in an area of the world at intermediate or loftier chance of hepatitis A transmission. Areas of low risk include the Usa, Canada, Japan, New Zealand, Australia and Western Europe. Visit the CDC's Traveler Health website for more information about 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 historic period 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 40 years who are planning travel to an expanse with high or intermediate HAV endemicity and have not received HepA vaccine should receive a single dose of HepA vaccine equally soon every bit travel is considered and should complete the ii-does series according to the routine schedule.

People with chronic liver disease equally well as adults older than 40 years of age, immunocompromised persons, and persons with other chronic medical weather 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 also simultaneously be administered IG at a separate anatomic injection site (for instance in split limbs).

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2018 to include vaccination of infants half-dozen through 11 months of age. 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 state of affairs. The travel-related dose for infants 6–11 months of historic period should not exist counted toward the routine 2-dose serial. 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 non to receive vaccine or for whom vaccine is contraindicated should receive a single 0.1 mL/kg dose of IG before travel when protection confronting HAV is recommended. If travel is for more than 1 month, a dose of 0.ii mL/kg should be administered. A 0.2 mL/kg dose tin can be repeated every 2 months for travel of more 2 months duration.

Can Twinrix be used for people planning international travel?

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

We have an adult patient who received the correct pediatric series of HepA vaccine equally a teenager and is now traveling away. 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 whatever historic period.

Is it really necessary to vaccinate travelers to Latin America who volition be staying in iv-star hotels?

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

If a traveler received the first dose of HepA vaccine more i year agone and needs to travel abroad imminently, will the traveler demand IG in improver to dose #ii prior to leaving?

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

If an babe younger than age 6 months receives IG before travel to a hepatitis A owned area, volition he/she need HepA vaccine earlier some other trip to a hepatitis A endemic expanse?

Perchance. Since IG protects against HAV infection for only ane to 2 months, depending on the dosage given, additional IG may exist needed if the infant is not yet age 6 months. Once the child has reached six months of age, HepA vaccine should be given.

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

Yes. ACIP recommends that all children age i year through 18 years should be vaccinated against hepatitis A. VFC HepA vaccine may exist administered to any eligible child, including those recommended for vaccination at 6 through eleven months of age every bit a result of travel to an HAV-owned area.

If a person was born and grew up in a country where HAV infection is endemic (eastward.m., Vietnam, Mexico) and then 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 immunity (positive test for full anti-HAV) is the but way to determine if vaccination is necessary. For people from countries with loftier rates of HAV infection, such equally Vietnam and Mexico, serologic testing might be done to prevent unnecessary vaccination. The cost effectiveness of serologic testing, however, should be balanced against the possibility of delaying needed vaccination while awaiting test results.

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

No, as long equally there are medical records that document that the person was previously infected with HAV (i.e., positive exam for full anti-HAV). If at that place is any doubtfulness 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 Safe Back to superlative

What reactions might occur later on administration of HepA vaccine?

No serious agin events accept been attributed definitively to HepA vaccine. Amidst adults, the most frequently reported side furnishings are soreness at the site of the injection and headache. In children, the most frequently reported side outcome is soreness at the injection site. The frequency of side furnishings after administration of Twinrix is like 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 severe allergic reaction to a previous dose of HepA vaccine or to a vaccine component. Every bit with all other vaccines, there is a precaution when giving it to anyone who is moderately or severely sick.

Can meaning women receive HepA vaccine?

Yes. ACIP recommends that pregnant women at risk for HAV infection during pregnancy or at risk for a severe outcome from HAV infection should be vaccinated during pregnancy if not previously vaccinated. Pregnant women should be vaccinated for the same indications as non-pregnant women. For additional details, come across page 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 harm 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 be vaccinated confronting hepatitis A if they have not been vaccinated, regardless of their CD4+ count.

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

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

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

Vaccine Storage and Handling

How should HepA vaccine be stored?

All hepatitis A-containing vaccine should be 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 exist used. Do not use these or any other vaccines after the expiration date shown on the packaging. Whatever vaccine administered subsequently its expiration date is non valid and should be repeated.

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

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