I Had a Hep a Vaccination When I Was Young

Hepatitis A

Disease Problems Allowed Globulin Vaccine Recommendations Travel - International For Special Groups Vaccine Prophylactic Administering Vaccines Contraindications and Precautions Twinrix Vaccine Storage and Treatment

Disease Issues

What is hepatitis A?

Hepatitis A is a liver affliction common in many parts of the world and acquired past hepatitis A virus (HAV), a picornavirus that causes acute 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?

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

Hepatitis A signs and symptoms normally resolve in 2-3 months, although ten% to 15% of symptomatic people take prolonged illness (usually referred to as relapsing hepatitis A) lasting up to 6 months and should exist considered infectious during that time.

How is HAV transmitted?

Person-to-person spread through the fecal-oral road is the primary means of HAV manual. Superlative infectivity in infected people occurs during the ii week period before the onset of jaundice when the concentration of virus in the stool is highest and most people are no longer infectious ane week after jaundice onset. Before routine vaccination of children was recommended, children were a fundamental source of infection because 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 desultory cases tin occur from exposure to fecally-contaminated food or water. Uncooked HAV-contaminated foods have been recognized as a source of outbreaks. Cooked foods also can transmit HAV if the temperature during food grooming is inadequate to kill the virus or if food is contaminated after cooking, as occurs in outbreaks associated with infected food handlers. Transmission of the virus from infected nutrient handlers to nutrient service establishment patrons is rare, accounting for 0.2% of the well-nigh 23,000 outbreak-associated cases of hepatitis A investigated by state wellness departments during 2016-2019.

Until 2017, US incidence rates of hepatitis A were driven by occasional outbreaks, often linked to viral contamination of imported nutrient. Since 2017, communitywide outbreaks take occurred more frequently, predominantly among people who are continued by specific risk factors, such every bit drug apply, and their close contacts.

What is the incubation menstruum for hepatitis A?

HAV can produce either asymptomatic or symptomatic infection in humans later on an average incubation flow 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. Peak infectivity occurs during the 2-calendar week menses before onset of jaundice or height of liver enzymes, when concentration of virus in stool is highest. Concentration of virus in stool declines after jaundice appears, with near people no longer infectious nearly a week after jaundice appears. Children can shed HAV for longer periods than adults, upwardly to 10 weeks or longer afterward onset of clinical disease.

How common is HAV infection in the Us?

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

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

Exercise people die from hepatitis A?

Yes. Decease as a result of fulminant hepatic failure is rare, still, older age (over 40 years) and preexisting chronic liver affliction increases the risk of severe disease and death from hepatitis A. The person-to-person U.S. multistate outbreaks that began in 2016 accept disproportionately affected adults with chronic liver illness and other health problems related to drug use and unstable housing. From 2016 through November 2021, CDC received reports of nearly 43,000 cases of astute HAV infection. Of these, approximately 61% take been hospitalized and one% (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 accept high or intermediate endemicity of HAV infection • Men who have sexual activity with men (MSM) • Users of injection and not-injection drugs (in other words, all who employ illegal drugs) • People with occupational risk of exposure (those who work with HAV-infected non-homo 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 grouping settings for those with developmental disabilities and other settings where hygiene is hard to maintain • People who are incarcerated

I thought people with clotting cistron disorders were at risk for hepatitis A due to their regular use of blood products. Why did ACIP make up one's mind to stop recommending routine vaccination of people with clotting gene disorders?

People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that fourth dimension, the process used to make clotting factor supplements did not 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 take drastically reduced that risk. In improver, more than than 80% of people with clotting factor disorders now receive recombinant clotting factor concentrates that are sterilized and take no gamble of HAV transmission. Every bit a result of these factors, people with clotting factor disorders now accept no greater risk of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless information technology is otherwise indicated.

Are people with developmental disabilities at risk of HAV infection?

Historically, HAV infection was highly endemic in institutions for people with developmental disabilities as a result of poor paw hygiene, shut living atmospheric condition and diaper utilize. As fewer children have been institutionalized and as weather in institutions have improved, the incidence and prevalence of HAV infection have decreased, although outbreaks can occur in these settings. All children with developmental disabilities should receive HepA according to U.S. routine vaccine recommendations, including take hold of up vaccination of all children through age xviii 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 electric current ACIP recommendations suggest considering HepA vaccination of residents and staff in facilities where hygiene is difficult to maintain, such every bit grouping 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 risk for acquiring HAV infection. However, they are at an increased risk for life-threatening, fulminant (severe and sudden) hepatitis if they become infected with hepatitis A. People considered to have chronic liver disease include those with hepatitis B or C infection, cirrhosis, fatty liver illness, alcoholic liver disease, and autoimmune hepatitis.

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

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

• Anti-HAV: Total antibody to HAV. This diagnostic test detects full antibiotic 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. It appears early in the form of infection, remains detectable for the person'south lifetime and provides lifelong protection against disease. Its presence indicates immunity through either HAV infection or HepA vaccination. • IgM anti-HAV: IgM antibody is a subclass of anti-HAV. Its presence indicates a recent infection with HAV (6 months or less). It is used to diagnose acute (recently caused) hepatitis A. Because of the take chances of false 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 also may be used to diagnose acute infection through the direct detection of viral RNA in serum or stool.

Total anti-HAV, which appears early in the form of infection, remains detectable for the person's lifetime and indicates lifelong protection against the infection/disease. To confirm a diagnosis of acute HAV infection, serologic testing for IgM anti-HAV is required. In the majority of persons, serum IgM anti-HAV becomes detectable 5 to 10 days earlier onset of symptoms and lasts about 6 months. However, there have been reports of persons who test positive for IgM anti-HAV for up to a twelvemonth or more following infection. An educational program on the interpretation of hepatitis A serology is available on the CDC website at www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm.

Can HAV be transmitted by blood?

Aye. On rare occasions, HAV infection has been transmitted past transfusion of blood or blood products collected from donors during the viremic phase of their infection (i.e., when HAV is in the donor's blood). Since 2002, tests to detect 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 mutual is HAV transmission in infirmary settings?

Hospital-caused 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 subsequently transmitted HAV to other infants and staff. Outbreaks of hepatitis A caused past transmission from adult patients to healthcare personnel (HCP) are typically associated with fecal incontinence and inadequate mitt hygiene, although the majority of hospitalized patients who accept hepatitis A are admitted after onset of jaundice, when they are across the point of peak infectivity. Transmission in healthcare settings also has resulted from breakdowns in standard infection command practices and manual from one healthcare provider to another.

How stable is HAV in the environment?

Depending on conditions, HAV can exist stable in the environment for months; freezing does not inactivate (i.eastward., return not-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 past disinfecting surfaces with a 1:100 dilution of sodium hypochlorite (i.e., household bleach) in tap h2o.

Fairly chlorinating water through water treatment processes and dilution in public water systems kills HAV. Spas and swimming pools that are fairly treated are not likely to pose a risk for HAV outbreaks.

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

No, there is no chronic (long-term) infection. Even the small proportion of people who develop relapsing HAV recover later almost half-dozen months. Once you have had HAV infection and recovered, you lot cannot get information technology again.

Vaccination Recommendations Back to top

What is the best way to forbid HAV infection?

Vaccination with the full series of hepatitis A vaccine (HepA) is the best way to forbid HAV infection. Immune globulin (IG) besides can be 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) 1-18 years 720 El.U.* 0.5 ml ii 0, 6-12 mos. 19 years and older 1440 El.U.* ane.0 ml two 0, 6-12 mos. Vaqta (Merck & Co.) 1-18 years 25 U** 0.5 ml ii 0, 6-18 mos. 19 years and older fifty U** 1.0 ml 2 0, half-dozen-18 mos.

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

Combination vaccine using hepatitis A and hepatitis B vaccines Vaccine Historic period group Antigens used Volume # Doses Schedule Twinrix (GSK) 18 years and older Havrix (720 El.U.) combined with Engerix-B (xx mcg) ane.0 ml 3 0, 1, 6 mos. 4 0, 7, 21-xxx 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 besides would benefit from hepatitis B protection. Twinrix is non recommended for use as post-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

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

Where tin can I find data about vaccine shortages?

For detailed data about HepA shortages, go to CDC'southward website at www.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 1 twelvemonth (12–23 months) • All children and adolescents historic period ii through 18 years who have not previously received HepA should be vaccinated (i.due east., routine catch-upwardly 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. Low endemicity regions include the U.s.a., Canada, Western Europe, Japan, New Zealand, and Australia. For more information, run into the CDC travel health website for current data nigh 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 doubt, vaccinate. • Infants historic period 6 through 11 months traveling outside the United States should receive 1 dose when protection against HAV infection is recommended. The travel dose does non count toward the routine HepA series which should be initiated at age i year with the appropriate dose and schedule. In these instances, the child will receive a total of 3 doses of HepA vaccine. • Men who have sexual 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 anticipate having close personal contact with an international adoptee from a country of loftier or intermediate endemicity during the first lx days following the adoptee'due south inflow in the U.S. • People who work with HAV-infected nonhuman primates or with HAV in a research laboratory setting • People with chronic liver disease (including just not limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or an ALT or AST level persistently greater than twice the upper limit of normal) • People identified during pregnancy to be at risk for HAV infection due to presence of a specific run a risk factor for exposure or at run a risk for severe result from HAV infection (for example, those with chronic liver disease or with HIV infection). • During an outbreak, any unvaccinated person who is identified as at risk for HAV infection or at risk for severe disease from HAV • Any person who wishes to exist immune to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, nutrient handlers, sewage workers, or twenty-four hours care providers because there is no evidence that their occupational risks of HAV exposure are significantly higher 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, see the 2020 recommendations of the Advisory Commission 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 eighteen years not previously vaccinated • [added] All people age 1 year or older living with HIV infection • [added] People identified to be at risk for HAV infection during pregnancy • [removed] People with clotting gene disorders

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

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

Which children should exist routinely vaccinated against HAV infection?

All children should receive 2 doses of HepA vaccine start at age 1 year (i.e., 12–23 months). The ii doses in the series should be administered at to the lowest degree 6 months apart. Whatever child age ii through eighteen 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 2-dose series is at least vi months. Is this the same as 24 weeks?

No. The minimum interval between dose #1 and #2 of HepA vaccine is 6 agenda months, not 24 weeks.

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

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

Good for you people who have completed the HepA vaccination series at any fourth dimension practise not demand additional 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 presently as possible, within 2 weeks of exposure.

People age 12 months and older exposed to HAV within the past fourteen days and who accept not 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 exist administered to people older than age twoscore years depending on the providers' hazard assessment. For long-term immunity, the HepA vaccine series should exist completed with a 2nd dose at least 6 months after the starting time dose. However, the second dose is non necessary for PEP. A second dose should not be administered sooner than 6 calendar months after the beginning dose, regardless of HAV exposure risk.

People historic period 12 months or older who are immunocompromised or accept chronic liver disease, and who accept been exposed to HAV within the past xiv days and have not previously completed the HepA vaccination series, should receive both IG (0.1 mL/kg) and HepA vaccine at the aforementioned visit in a different anatomic site (for example, separate limbs) as shortly every bit possible later on exposure. For long-term immunity, the HepA vaccination series should be completed with a 2d dose at least 6 months after the first dose. Even so, the second dose is non necessary for PEP. A second dose should not be administered sooner than 6 calendar months after the first dose, regardless of HAV exposure hazard.

People with HIV infection develop protective levels of antibody more slowly and are less likely to develop protective antibody levels after vaccination with HepA, particularly if their CD4+ count is depression at the time of vaccination. Protection following vaccination of a person with HIV may wane over time. Vaccine should be administered if the exposed individual is non fully vaccinated; however, CDC besides advises clinicians to consider administering IG PEP to an private with HIV after a high-take chances 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 as a standard single-dose developed HepA vaccine. Twinrix should non be used for PEP but may exist used to confer protection to at-chance just not however exposed persons during an outbreak.

Infants younger than historic period 12 months and persons for whom vaccine is contraindicated should receive IG (0.ane mL/kg) instead of HepA vaccine as soon as possible and inside 2 weeks of exposure. MMR and varicella vaccines should not be administered sooner than half-dozen months afterward 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 low prevalence of infection in children. Information technology besides is not routinely recommended for adults but may exist considered in some settings to reduce costs associated with vaccinating people who are already immune. Prevaccination testing should not exist used if it poses a barrier to vaccinating susceptible people, peculiarly people who are difficult to access.

Prevaccination testing is about probable to exist cost-constructive for adults who were either built-in in or lived for long periods of time in areas of the world with high or intermediate hepatitis A endemicity. When evaluating people from populations with high rates of previous HAV infection, vaccination history besides should be obtained, if feasible. If testing or vaccination history is not available, practise non postpone vaccinating. There is no damage 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 non necessary later on routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibody i month or more than after completing the HepA vaccination series is recommended only for people whose time to come clinical direction depends on knowing their immune status and for whom revaccination might be 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 practice not bear witness an adequate immune response (10 mIU/mL or higher), revaccination with a complete serial is recommended, followed by a second postvaccination serologic test. If that second examination remains negative, no additional vaccination is recommended; nonetheless, 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 data are available to brand 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 confronting HAV infection for all previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days post-obit the adoptee's arrival in the U.Southward. 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 get-go dose of HepA should be given to close contacts as soon as adoption is planned, ideally at least two weeks before the inflow of the adoptee. A 2d dose should be given no sooner than 6 months afterwards the beginning 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 i) a person who lacks housing (regardless of whether the person is a member of a family), including a person whose primary residence during the nighttime is a supervised public or private facility (eastward.g., 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, unmarried-room occupancy facility, abased edifice, vehicle, or whatever other unstable or nonpermanent situation, or 3) who is "doubled up", a term that refers to a situation where persons are unable to maintain their housing situation and are forced to stay with a series of friends or extended family unit members. In addition, previously homeless persons who are to be released from a prison or a hospital might be considered homeless if they do not accept a stable housing situation to which they tin return. The instability of a person's living arrangements is critical to the definition of homelessness.

Some people on my squad are worried about initiating the HepA vaccine series in people who are homeless because we may not exist able to complete the series or keep up with their records over time. How much of a concern is this?

While a complete 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 than 10 years and can preclude or command outbreaks of hepatitis A. People who are experiencing homelessness may accept difficulty protecting themselves from exposure to HAV in other means because of their living conditions. They should be vaccinated when possible and provided a tape of immunization. Reporting the HepA vaccination to a state immunization information system also can facilitate immunization assessment at hereafter healthcare encounters.

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

No. A number of studies have shown that HCP are non at significantly increased risk of HAV infection because of their occupation. However, if HCPs are going to work (or vacation) in a state with a loftier or intermediate endemic rate of HAV infection, they are at risk of HAV infection and should be vaccinated. The but occupational indications for routine HepA vaccination are work with non-human primates or live HAV in a laboratory setting.

Should daycare workers exist routinely vaccinated against hepatitis A?

No. In the by, outbreaks of hepatitis A occurred among children in kid intendance centers, infecting employees of those centers, especially those caring for infants and toddlers. Following widespread adoption of early on childhood vaccination against hepatitis A, outbreaks in child care centers are at present 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 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 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 have been reported amongst wastewater workers in the U.s.a.. In add-on, in the United States, outbreaks of hepatitis A acquired past flooding, which can carry raw sewage, have not been reported.

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

People with clotting gene disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that fourth dimension, the process used to make clotting factor supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased take chances of HAV infection. Modern claret donor screening and virus reduction steps have drastically reduced that risk. In addition, more than than 80% of people with clotting cistron disorders now receive recombinant clotting factor concentrates that are sterilized and have no risk of HAV transmission. As a result of these factors, people with clotting factor disorders at present have no greater risk 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 non recommended) for infant travelers age 6 through 11 months at risk of exposure to HAV?

Considering of measles. Measles is highly catching and poses a serious threat to the health of unvaccinated infants. For this reason, all infants age vi through 11 months who travel internationally are recommended to receive a dose of measles, mumps, and rubella vaccine (MMR) to reduce the gamble of measles infection during travel.

The antibodies in immune globulin (IG) typically used to forbid HAV infection in infants earlier the first birthday can interfere with the effectiveness of MMR vaccine. An infant who is given IG should not be vaccinated with MMR or varicella vaccines for at least six months after IG administration. If an babe historic period 6 through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-label use of HepA vaccine (not IG) in addition to MMR. The HepA and MMR doses administered before the first altogether practice not count toward the routine vaccination series of either vaccine: these baby travelers volition withal need 2 doses of HepA and 2 doses of MMR when age advisable.

Tin pregnant women receive hepatitis A vaccine?

Yes. The ACIP recommends that meaning women at take a chance for HAV infection during pregnancy or at run a risk for a severe outcome from HAV infection should be vaccinated during pregnancy if non previously vaccinated. Meaning women should be vaccinated for the aforementioned indications equally non-pregnant women. For additional information, see page twenty of the recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Administering Vaccines Back to top

By what method should hepatitis A vaccine exist administered?

Hepatitis A vaccine (HepA) should exist administered intramuscularly (IM), using the appropriate injection site and needle size as determined by the patient's age and torso mass.

Tin can HepA vaccine exist given concurrently with other vaccines?

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

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

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

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

You lot do not need to first the series 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 it is important to administer the second dose.

To complete a 21-year-old patient's 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 appropriate for their historic period at the time of administration. You lot should give the patient one adult dose of HepA to consummate the 2-dose series. Information technology is not necessary to restart the vaccine series.

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

In general, if the error is discovered on the same clinic day, you lot can administrate the other "half" of the dose on that same 24-hour interval. If the error is discovered later on, the dose should non be counted, and so the person should exist recalled to the office and given a full age-advisable repeat dose.

If you 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 near the error. In that location may be an increased take chances of a local adverse reaction when more than the recommended dose is given. If the error occurred with the showtime dose of the series the child should still receive the 2d dose on schedule. Giving a "double" dose for the first dose does not negate the need for a 2d dose.

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

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

The efficacy data from the clinical trials were based on historic period at time of vaccination, and non on the weight of the individual. Hence, the dosage recommendations reflect this age-based efficacy data. The same holds truthful for HepB vaccine. In addition, higher response rates are expected in younger people, even if their weights are above 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 (one-half of the Havrix adult dose) and 20 mcg of hepatitis B antigen (the total Engerix-B adult dose).

In the U.S., Twinrix is licensed for use in people who are age xviii years or older. It can be administered to people who are at risk for both hepatitis A and hepatitis B, such as certain international travelers, people with HIV infection, people with chronic liver disease not caused by hepatitis B, men who have sex with men, illegal drug users, or to people who simply want to be immune to both diseases. Main immunization consists of 3 doses given intramuscularly on a 0, i, and 6 month schedule. In 2007, the FDA also approved a four-dose schedule for Twinrix. It consists of 3 doses given within iv weeks, followed by a booster dose at 12 months (0, 7 days, 21–xxx days, and 12 months). The 4-dose schedule could benefit individuals needing rapid protection from hepatitis A and hepatitis B, such every bit people traveling to high-prevalence areas imminently.

Twinrix cannot exist used for postexposure prophylaxis.

I have seen adults who take had 1 or 2 doses of Twinrix, but we merely carry single-antigen vaccine in our practice. How should nosotros consummate their vaccination serial with single-antigen vaccines?

Twinrix is licensed as a iii-dose serial for people age xviii years and older. If Twinrix is not available or if you choose not to utilize Twinrix to complete the Twinrix serial, you should exercise the following: If one dose of Twinrix was given, consummate the series with 2 developed doses of hepatitis B vaccine and 2 adult doses of hepatitis A vaccine. If 2 doses of Twinrix were given, consummate 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 can be substituted for any dose of the hepatitis B series but not for any dose of the hepatitis A serial.

• Any combination of three doses of adult hepatitis B or 3 doses of Twinrix is a complete series of hepatitis B vaccine. • 1 dose of Twinrix + 2 doses of adult hepatitis A is a complete series of hepatitis A vaccine. • Two doses of Twinrix + 1 dose of adult hepatitis A is a complete series of hepatitis A vaccine.

We're thinking of using Twinrix and nosotros're wondering whether nosotros can use it for doses #1 and #3 only and apply 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, three doses of Twinrix must comprise the serial.

Allowed Globulin Dorsum to top

What is allowed globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile training of full-bodied antibodies (i.eastward., immunoglobulins) made from pooled human plasma processed by cold ethanol fractionation. GamaSTAN is the simply IG product licensed in the United States for the prevention of hepatitis A. Simply plasma that has tested negative for hepatitis B surface antigen, antibody to human immunodeficiency virus (HIV), and antibody to hepatitis C virus (HCV) is used to produce IG. In add-on, the Food and Drug Administration requires that the process used to produce IG include a viral inactivation stride or that final products test negative for HCV-RNA by polymerase chain reaction. Anti-HAV concentrations differ amidst IG lots and decreasing concentrations accept been observed over the past 30 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 reverberate this change in anti-HAV potency.

How does immune globulin (IG) work?

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

When administered for preexposure prophylaxis, a dose of 0.one mL/kg will provide protection for upwardly to i month and a dose of 0.2 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 exist repeated every 2 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.ane mL/kg.

How is IG packaged and how is IG administered?

Intramuscular IG is available in single-apply vials (2 mL and 10 mL). It should be administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Practice not employ the gluteal region every bit an injection site because of the gamble of injury to the sciatic nervus.

Does IG cause agin 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 take been associated with the formation of claret clots (thrombosis) later administration, particularly if the patient has other take a chance factors for thrombosis. Patients should be counseled nigh this risk.

Can meaning or lactating women receive IG?

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

A child in my exercise was given hepatitis A IG (GamaSTAN, Grifols) when she was ten months old after her mother tested positive for hepatitis A. She'southward scheduled for her 12-calendar month-old well-child visit. Will this bear on her vaccination schedule?

Yes. IG may exist given any time earlier or afterwards inactivated vaccines. Still, the antibodies in IG may interfere with the effectiveness of certain alive-virus vaccines, such every bit measles, mumps, and rubella (MMR) and varicella vaccines. CDC recommends waiting at least six months from the engagement of IG administration earlier 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: www.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 historic period 6 months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver disease vaccinated within two weeks of deviation may consider IG in add-on to vaccination, based upon the clinician's risk assessment • Previously unvaccinated people who are immunocompromised may consider IG in add-on to vaccination, regardless of the timing of vaccination, based upon the clinician's adventure assessment • Previously unvaccinated people who are over age 40 years and vaccinated within 2 weeks of departure may consider IG in addition to vaccination, based upon the clinician's risk cess

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

• Infants under age 12 months • Previously unvaccinated immunocompromised adults (including HIV+), in addition to vaccination • Previously unvaccinated adults with chronic liver disease, in improver to vaccination • Previously unvaccinated adults over age xl years, consider IG in addition to vaccination, based upon clinician risk assessment • People with HIV infection, previously vaccinated, consider IG following a loftier-hazard exposure (household or sexual contact), based upon clinician chance cess

Travel - International Back to top

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people historic period half dozen months or older who are traveling to or working in an area of the earth at intermediate or high risk of hepatitis A transmission. Areas of low adventure include the U.s.a., Canada, Japan, New Zealand, Australia and Western Europe. Visit the CDC'south Traveler Wellness website for more data 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 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.

Good for you people age 12 months through xl years who are planning travel to an area with loftier or intermediate HAV endemicity and have non received HepA vaccine should receive a unmarried dose of HepA vaccine as soon as travel is considered and should consummate the 2-does serial co-ordinate to the routine schedule.

People with chronic liver illness as well as adults older than forty years of age, immunocompromised persons, and persons with other chronic medical conditions planning to depart to an expanse with loftier or intermediate HAV endemicity in less than two weeks should receive the initial dose of HepA vaccine and may also simultaneously be administered IG at a carve up anatomic injection site (for case in separate limbs).

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2018 to include vaccination of infants half-dozen through xi months of age. All infants of this age traveling internationally should be given a dose of measles, mumps, rubella vaccine (MMR) earlier 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 situation. The travel-related dose for infants vi–11 months of age should not be counted toward the routine two-dose series. The routine ii-dose HepA and MMR vaccination serial should be initiated at age 12 months co-ordinate to the routine, age-appropriate vaccination schedule.

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

Tin Twinrix exist used for people planning international travel?

Yes. If time allows, employ the standard Twinrix schedule of three 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 3 doses given on days 0, vii, and 21-thirty days and a booster dose at 12 months.

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

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

Is it actually necessary to vaccinate travelers to Latin America who will be staying in four-star hotels?

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

If a traveler received the kickoff dose of HepA vaccine more than one yr ago and needs to travel abroad imminently, will the traveler need IG in addition to dose #2 prior to leaving?

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

If an infant younger than historic period half dozen months receives IG before travel to a hepatitis A endemic surface area, volition he/she need HepA vaccine before some other trip to a hepatitis A endemic area?

Possibly. Since IG protects confronting HAV infection for only i to 2 months, depending on the dosage given, additional IG may be needed if the infant is not all the same age half dozen months. One time the child has reached vi months of age, HepA vaccine should be given.

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

Yeah. ACIP recommends that all children historic period one yr through 18 years should be vaccinated against hepatitis A. VFC HepA vaccine may exist administered to whatsoever eligible kid, including those recommended for vaccination at half dozen through xi months of age every bit a consequence of travel to an HAV-endemic surface area.

If a person was born and grew up in a country where HAV infection is endemic (e.g., Vietnam, Mexico) and then moved to the United States at historic period 20, should that person receive HepA vaccine before returning to visit his/her homeland?

Information technology depends on whether that person has a history of HAV infection. Unless there are medical records that document prior HAV infection, serologic testing for immunity (positive test for total anti-HAV) is the merely style to decide if vaccination is necessary. For people from countries with high rates of HAV infection, such as Vietnam and Mexico, serologic testing might exist done to prevent unnecessary vaccination. The price effectiveness of serologic testing, however, should be balanced confronting 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, every bit long every bit there are medical records that document that the person was previously infected with HAV (i.e., positive test for total anti-HAV). If at that place is any doubt that the person actually was infected with HAV, HepA vaccine and/or IG should be given. The vaccine or IG will not harm a person who is already allowed.

Vaccine Safety Back to top

What reactions might occur later on assistants of HepA vaccine?

No serious adverse events have been attributed definitively to HepA vaccine. Amidst adults, the nigh frequently reported side effects are soreness at the site of the injection and headache. In children, the most oftentimes reported side effect is soreness at the injection site. The frequency of side effects after administration of Twinrix is like to those reported when the ii unmarried-antigen vaccines were administered.

Contraindications and Precautions Back to top

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

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

Can meaning women receive HepA vaccine?

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

Can lactating women receive HepA vaccine?

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

Tin HepA vaccine exist given to immunocompromised people?

Yes. All people historic period 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 whatever immunocompromised person has a risk cistron that places them at increased risk of hepatitis A (eastward.thousand., international travel, drug use), they should be vaccinated with HepA vaccine.

I accept a patient on interferon for hepatitis C, simply I want to give him HepA vaccine. Is information technology okay to vaccinate him against hepatitis A while he is on interferon?

Yes. 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 fridge 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 non be used. Do not use these or any other vaccines after the expiration date shown on the packaging. Any vaccine administered after its expiration engagement is not valid and should be repeated.

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