I Had a Hep a Vaccine Years Ago Do I Need It Again

Hepatitis A

Disease Issues Immune Globulin Vaccine Recommendations Travel - International For Special Groups Vaccine Condom Administering Vaccines Contraindications and Precautions Twinrix Vaccine Storage and Treatment

Illness Issues

What is hepatitis A?

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

What are the signs and symptoms of hepatitis A?

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

Hepatitis A signs and symptoms unremarkably resolve in 2-3 months, although 10% to 15% of symptomatic people accept prolonged disease (usually referred to equally relapsing hepatitis A) lasting upwards to half-dozen months and should be considered infectious during that time.

How is HAV transmitted?

Person-to-person spread through the fecal-oral route is the primary means of HAV transmission. 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 almost people are no longer infectious one week subsequently jaundice onset. Before routine vaccination of children was recommended, children were a primal source of infection because well-nigh infected children had no symptoms and could shed virus in stool for weeks or months. Transmission currently occurs primarily among susceptible adults.

Common-source outbreaks and sporadic cases tin occur from exposure to fecally-contaminated food or water. Uncooked HAV-contaminated foods take been recognized every bit a source of outbreaks. Cooked foods too can transmit HAV if the temperature during food preparation is inadequate to kill the virus or if food is contaminated afterwards cooking, as occurs in outbreaks associated with infected nutrient handlers. Manual of the virus from infected food handlers to food service establishment patrons is rare, bookkeeping for 0.2% of the nearly 23,000 outbreak-associated cases of hepatitis A investigated by state health departments during 2016-2019.

Until 2017, US incidence rates of hepatitis A were driven past occasional outbreaks, often linked to viral contamination of imported food. Since 2017, communitywide outbreaks have occurred more oftentimes, predominantly among people who are connected past specific run a risk factors, such every bit drug use, and their close contacts.

What is the incubation menstruum for hepatitis A?

HAV tin can produce either asymptomatic or symptomatic infection in humans after an average incubation period of 28 days (range: 15–50 days).

How is HAV shed?

In infected people, HAV replicates in the liver, is excreted in bile, and is shed in stool. Top infectivity occurs during the ii-calendar week flow earlier onset of jaundice or elevation of liver enzymes, when concentration of virus in stool is highest. Concentration of virus in stool declines later on jaundice appears, with well-nigh people no longer infectious about a calendar week after jaundice appears. Children tin can shed HAV for longer periods than adults, upwards to 10 weeks or longer after onset of clinical disease.

How common is HAV infection in the United states of america?

The incidence of hepatitis A in the United states increased more than 10-fold from 2022 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 about 37,700 cases actually occurred in 2019.

Between 2012 and 2022 the number of reported hepatitis A infections ranged from approximately 1200 to 1800 cases every twelvemonth. Commencement in 2016, large foodborne outbreaks led to an increase in the number of cases and sustained, large person-to-person outbreaks began, primarily driven by infections among unvaccinated people who use drugs and people experiencing homelessness and their contacts. Since so, persistent person-to-person outbreaks accept led to substantial increases in hepatitis A infection, with reported cases increasing by over 50% from 2022 to 2019. More information regarding ongoing multistate outbreaks tin can be found here: www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Do people die from hepatitis A?

Yes. Death every bit a issue of fulminant hepatic failure is rare, notwithstanding, older age (over 40 years) and preexisting chronic liver disease increases the take a chance of severe disease and death from hepatitis A. The person-to-person U.South. multistate outbreaks that began in 2022 accept disproportionately affected adults with chronic liver disease and other health bug related to drug use and unstable housing. From 2022 through Nov 2021, CDC received reports of nearly 43,000 cases of acute HAV infection. Of these, approximately 61% accept been hospitalized and 1% (more than 400 people) have died.

Who is most at risk for acquiring HAV infection?

People who are at increased take a chance for acquiring HAV infection include the post-obit:

• Travelers to countries that have high or intermediate endemicity of HAV infection • Men who accept sex with men (MSM) • Users of injection and not-injection drugs (in other words, all who utilize illegal drugs) • People with occupational risk of exposure (those who piece of 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 cistron disorders were at risk for hepatitis A due to their regular apply of blood products. Why did ACIP determine to terminate 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 gene supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of HAV infection. Mod blood donor screening and virus reduction steps have drastically reduced that risk. In addition, more than 80% of people with clotting factor disorders now receive recombinant clotting cistron concentrates that are sterilized and take no hazard of HAV transmission. As a result of these factors, people with clotting cistron disorders now have no greater risk 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 risk of HAV infection?

Historically, HAV infection was highly owned in institutions for people with developmental disabilities as a consequence of poor mitt hygiene, close living conditions and diaper utilize. As fewer children have been institutionalized and every bit atmospheric condition in institutions take 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.South. routine vaccine recommendations, including catch upwardly vaccination of all children through age 18 years.

As a strategy to farther reduce the chance of hepatitis A outbreaks and reach adults in settings with a high proportion of people with chance 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 equally group homes for people with developmental disabilities and homeless shelters.

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

No. People with chronic liver disease are not at increased chance for acquiring HAV infection. Withal, 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 affliction, alcoholic liver disease, and autoimmune hepatitis.

Please discuss the tests commonly used to diagnose hepatitis A.

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

• Anti-HAV: Total antibody to HAV. This diagnostic test detects full antibody of both IgG and IgM subclasses of HAV. If positive, it indicates either acute or resolved infection. • IgG anti-HAV: IgG antibody is a subclass of anti-HAV. Information technology appears early in the course of infection, remains detectable for the person's lifetime and provides lifelong protection confronting illness. 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 (vi months or less). It is used to diagnose astute (recently acquired) hepatitis A. Because of the risk of false positive IgM anti-HAV results, people should only be tested for IgM anti-HAV if they are symptomatic and suspected of having astute hepatitis A illness. • HAV RNA tests besides may be used to diagnose acute infection through the directly detection of viral RNA in serum or stool.

Full anti-HAV, which appears early in the course of infection, remains detectable for the person's lifetime and indicates lifelong protection against the infection/disease. To ostend a diagnosis of astute HAV infection, serologic testing for IgM anti-HAV is required. In the majority of persons, serum IgM anti-HAV becomes detectable 5 to 10 days earlier onset of symptoms and lasts almost vi months. However, in that location take been reports of persons who test positive for IgM anti-HAV for upward to a yr or more than following infection. An educational program on the interpretation of hepatitis A serology is available on the CDC website at www.cdc.gov/hepatitis/resource/professionals/preparation/serology/training.htm.

Can HAV exist transmitted by blood?

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

Is HAV transmitted by saliva?

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

How common is HAV transmission in infirmary settings?

Hospital-caused HAV infection is rare. In the past, outbreaks were observed in neonatal intensive care units when infants acquired infection from HAV-infected transfused blood and later transmitted HAV to other infants and staff. Outbreaks of hepatitis A caused past manual from adult patients to healthcare personnel (HCP) are typically associated with fecal incontinence and inadequate hand hygiene, although the majority of hospitalized patients who have hepatitis A are admitted after onset of jaundice, when they are beyond the betoken of pinnacle infectivity. Transmission in healthcare settings also has resulted from breakdowns in standard infection control practices and manual from one healthcare provider to another.

How stable is HAV in the environment?

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

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

Practice people with hepatitis A develop chronic disease or tin they become repeated infections?

No, there is no chronic (long-term) infection. Even the small proportion of people who develop relapsing HAV recover subsequently most six months. Once y'all have had HAV infection and recovered, you lot cannot become it again.

Vaccination Recommendations Back to top

What is the all-time way to foreclose HAV infection?

Vaccination with the full serial of hepatitis A vaccine (HepA) is the best way to prevent HAV infection. Allowed globulin (IG) besides tin can be used for short-term protection in certain situations.

What are the hepatitis A vaccines (HepA) that are canonical 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. nineteen years and older 1440 El.U.* i.0 ml 2 0, 6-12 mos. Vaqta (Merck & Co.) 1-18 years 25 U** 0.5 ml ii 0, six-xviii mos. 19 years and older l U** 1.0 ml 2 0, 6-18 mos.

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

Combination vaccine using hepatitis A and hepatitis B vaccines Vaccine Age group Antigens used Volume # Doses Schedule Twinrix (GSK) 18 years and older Havrix (720 El.U.) combined with Engerix-B (20 mcg) 1.0 ml 3 0, i, 6 mos. 4 0, 7, 21-30 days, 12 months***

*** Accelerated schedule may exist used for rapid protection prior to travel or for rapid protection of an unexposed simply at-hazard person who also would do good from hepatitis B protection. Twinrix is not recommended for utilize as postal service-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

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

Where tin I observe information about vaccine shortages?

For detailed information virtually 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 Advisory Committee on Immunization Practices (ACIP) recommends routine HepA vaccination for the following groups:

• All children at historic period 1 year (12–23 months) • All children and adolescents age 2 through 18 years who have not previously received HepA should be vaccinated (i.due east., routine catch-upwards vaccination) [2020] • People living with HIV infection [2020] • Travelers historic period 12 months and older to areas of the world with intermediate or high HAV endemicity. Low endemicity regions include the United States, Canada, Western Europe, Japan, New Zealand, and Australia. For more information, see the CDC travel wellness website for electric current information about specific countries at www.cdc.gov/travel or the CDC Yellow Book (wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-a). When in doubt, vaccinate. • Infants age 6 through xi months traveling outside the The states should receive i dose when protection confronting HAV infection is recommended. The travel dose does not count toward the routine HepA series which should be initiated at age 1 yr with the advisable dose and schedule. In these instances, the child will receive a full of three doses of HepA vaccine. • Men who take sex with men • Users of illegal drugs, injectable or noninjectable • People who are homeless or in unstable living arrangements, including shelters • Previously unvaccinated people who anticipate having close personal contact with an international adoptee from a state of loftier or intermediate endemicity during the first 60 days following the adoptee's arrival in the U.S. • People who work with HAV-infected nonhuman primates or with HAV in a enquiry laboratory setting • People with chronic liver disease (including simply not limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver affliction, autoimmune hepatitis, or an ALT or AST level persistently greater than twice the upper limit of normal) • People identified during pregnancy to be at risk for HAV infection due to presence of a specific risk factor for exposure or at risk for astringent outcome from HAV infection (for example, those with chronic liver illness 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 • Whatever person who wishes to exist allowed to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, food handlers, sewage workers, or mean solar day care providers considering 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, meet the 2022 recommendations of the Informational 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 2022 ACIP statement?

• [added] All children ages ii through 18 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 factor disorders

Should we requite HepA to a person older than historic period eighteen years who requests it?

Yeah, 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 age 1 twelvemonth (i.due east., 12–23 months). The 2 doses in the series should exist administered at least 6 months autonomously. Any child historic period 2 through 18 years non previously vaccinated should exist 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 6 months. Is this the same as 24 weeks?

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

I take a kid who was given her 2nd dose of hepatitis A vaccine 4 months subsequently the first dose. Does it need to be repeated, and if then, when?

Yep. The second dose was given more than four days before the minimum interval of 6 calendar months, so it is considered invalid and should be repeated. The repeat dose should be administered the proper minimum interval (six months) after the invalid dose. If this repeat dose is inadvertently given less than vi months afterwards the invalid dose, information technology does not demand to be repeated again as long as the interval between the initial HepA vaccine and the nearly 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). Please see the consummate PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attention to Table 4 on page 19 and Appendix B: Provider Guidance on Take a chance Assessment for Hepatitis A Postexposure Prophylaxis, showtime on page 36.

Healthy people who accept completed the HepA vaccination series at whatsoever time do non need additional PEP if they are exposed to HAV. People who have recently been exposed to HAV and who have not received HepA vaccine previously should receive PEP as presently as possible, within two weeks of exposure.

People age 12 months and older exposed to HAV within the past 14 days and who have not previously completed the HepA vaccine series should receive a single dose of HepA vaccine as presently 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' risk assessment. For long-term immunity, the HepA vaccine series should be completed with a 2nd dose at least 6 months after the starting time dose. However, the 2d dose is not necessary for PEP. A second dose should not exist administered sooner than 6 calendar months later the first dose, regardless of HAV exposure risk.

People age 12 months or older who are immunocompromised or have chronic liver disease, and who have been exposed to HAV within the past 14 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 unlike anatomic site (for example, separate limbs) as soon as possible after exposure. For long-term amnesty, the HepA vaccination serial should be completed with a 2nd dose at least half-dozen months later on the first dose. All the same, the 2nd dose is not necessary for PEP. A 2d dose should non exist administered sooner than 6 calendar months after the start dose, regardless of HAV exposure risk.

People with HIV infection develop protective levels of antibody more slowly and are less likely 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 after a high-risk exposure (such as a household or sexual contact) even if the private has been fully vaccinated.

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

Infants younger than historic period 12 months and persons for whom vaccine is contraindicated should receive IG (0.1 mL/kg) instead of HepA vaccine equally soon as possible and within two weeks of exposure. MMR and varicella vaccines should non be administered sooner than 6 months subsequently IG administration in club 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 total anti-HAV or IgG anti-HAV) is non indicated for children because of the low prevalence of infection in children. Information technology also is non 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 non exist used if it poses a bulwark to vaccinating susceptible people, especially people who are difficult to access.

Prevaccination testing is well-nigh likely to exist cost-effective for adults who were either born in or lived for long periods of fourth dimension in areas of the world with high or intermediate hepatitis A endemicity. When evaluating people from populations with loftier rates of previous HAV infection, vaccination history likewise should be obtained, if feasible. If testing or vaccination history is not available, do 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 not necessary subsequently routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibody one month or more than afterwards completing the HepA vaccination series is recommended only for people whose future clinical management depends on knowing their allowed 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 allowed response (x mIU/mL or higher), revaccination with a complete series is recommended, followed by a second postvaccination serologic test. If that second test remains negative, no additional vaccination is recommended; however, the patient should be counseled on strategies to avoid exposure to HAV and the need for IG if an exposure occurs. If vaccination results in seroconversion, insufficient information are available to make recommendations apropos echo testing, booster doses or revaccination.

For Special Groups Back to top

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

ACIP recommends vaccination against HAV infection for all previously unvaccinated people who conceptualize having shut personal contact with an international adoptee from a state of high or intermediate endemicity during the get-go 60 days following the adoptee's inflow in the U.S. In addition to the adoptee's new parents and siblings, this group might include grandparents, other household members, regular babysitters and other caregivers. The first dose of HepA should be given to shut contacts every bit soon every bit adoption is planned, ideally at least ii weeks before the arrival of the adoptee. A second dose should be given no sooner than 6 months later the beginning dose.

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

The 2022 ACIP recommendations for the prevention of hepatitis A define a person experiencing homelessness equally 1) a person who lacks housing (regardless of whether the person is a member of a family), including a person whose primary residence during the night is a supervised public or private facility (e.g., shelter) that provides temporary living accommodations and a person who is a resident in transitional housing, 2) a person without permanent housing who might: alive on the streets, stay in a shelter, mission, single-room occupancy facility, abandoned edifice, vehicle, or any other unstable or nonpermanent situation, or iii) who is "doubled upward", a term that refers to a situation where persons are unable to maintain their housing situation and are forced to stay with a serial of friends or extended family members. In add-on, previously homeless persons who are to be released from a prison or a infirmary might be considered homeless if they exercise not have a stable housing state of affairs to which they tin can return. The instability of a person'south living arrangements is critical to the definition of homelessness.

Some people on my team are worried about initiating the HepA vaccine serial in people who are homeless considering we may not be able to complete the series or continue upwardly with their records over time. How much of a business is this?

While a complete series 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 than 10 years and can prevent 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 record of immunization. Reporting the HepA vaccination to a state immunization information organisation besides can facilitate immunization cess at future healthcare encounters.

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

No. A number of studies accept shown that HCP are not at significantly increased take a chance of HAV infection because of their occupation. Yet, if HCPs are going to work (or vacation) in a land with a high or intermediate endemic rate of HAV infection, they are at risk of HAV infection and should be vaccinated. The only occupational indications for routine HepA vaccination are work with non-human primates or live HAV in a laboratory setting.

Should daycare workers be routinely vaccinated confronting hepatitis A?

No. In the past, outbreaks of hepatitis A occurred amongst children in child care centers, infecting employees of those centers, peculiarly those caring for infants and toddlers. Following widespread adoption of early 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 illness?

Although non at increased risk for HAV infection, people with chronic liver illness 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 comparing populations, no substantial or consistent increase in the prevalence of anti-HAV was identified amidst wastewater workers. No piece of work-related instances of HAV transmission have been reported among wastewater workers in the United States. In addition, in the The states, outbreaks of hepatitis A caused by flooding, which tin can carry raw sewage, have non 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 cistron 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 have drastically reduced that chance. In addition, more than 80% of people with clotting gene disorders now receive recombinant clotting cistron concentrates that are sterilized and take no risk of HAV transmission. As a result of these factors, people with clotting factor disorders now have no greater hazard 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 historic period half-dozen through eleven months at chance of exposure to HAV?

Because of measles. Measles is highly communicable and poses a serious threat to the health 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 immune globulin (IG) typically used to preclude HAV infection in infants earlier the starting time birthday can interfere with the effectiveness of MMR vaccine. An infant who is given IG should not exist vaccinated with MMR or varicella vaccines for at least half dozen months subsequently IG assistants. If an infant historic period 6 through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-characterization apply of HepA vaccine (not IG) in addition to MMR. The HepA and MMR doses administered earlier the first birthday practice not count toward the routine vaccination series of either vaccine: these infant travelers will still need ii doses of HepA and two doses of MMR when age appropriate.

Can pregnant women receive hepatitis A vaccine?

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

Administering Vaccines Back to top

Past what method should hepatitis A vaccine be administered?

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

Tin HepA vaccine be given concurrently with other vaccines?

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

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

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

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

You do non need to beginning the series over once again. The immunogenicity of ane dose of HepA vaccine is 94% to 100%; studies have shown persistent protection from a single dose lasting more 10 years. To ensure optimal long-term protection information technology is important to administrate the second dose.

To complete a 21-year-sometime 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 age at the time of administration. You should give the patient i adult dose of HepA to complete the 2-dose serial. It is not necessary to restart the vaccine series.

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

In general, if the error is discovered on the same dispensary day, you can administer the other "half" of the dose on that aforementioned solar day. If the error is discovered later, the dose should non be counted, and then the person should be recalled to the office and given a total historic period-advisable repeat dose.

If y'all give more an age-appropriate dose (for case, 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 agin reaction when more than the recommended dose is given. If the error occurred with the outset dose of the series the kid should still receive the second dose on schedule. Giving a "double" dose for the kickoff dose does not negate the need for a 2nd dose.

Avoid such errors by checking the vaccine vial label iii 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 age at fourth dimension of vaccination, and not on the weight of the individual. Hence, the dosage recommendations reflect this historic period-based efficacy information. The same holds truthful for HepB vaccine. In improver, college response rates are expected in younger people, even if their weights are in a higher place the norm.

Could you please provide more data well-nigh Twinrix (the combination hepatitis A and B vaccine) and the two schedules for its apply?

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

In the U.South., Twinrix is licensed for use in people who are age xviii years or older. It tin be administered to people who are at risk for both hepatitis A and hepatitis B, such as sure international travelers, people with HIV infection, people with chronic liver illness non acquired by hepatitis B, men who have sex with men, illegal drug users, or to people who merely want to be immune to both diseases. Primary immunization consists of iii doses given intramuscularly on a 0, 1, and 6 calendar month schedule. In 2007, the FDA as well canonical a four-dose schedule for Twinrix. It consists of 3 doses given within four weeks, followed by a booster dose at 12 months (0, 7 days, 21–30 days, and 12 months). The 4-dose schedule could benefit individuals needing rapid protection from hepatitis A and hepatitis B, such as people traveling to loftier-prevalence areas imminently.

Twinrix cannot be used for postexposure prophylaxis.

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

Twinrix is licensed as a three-dose series for people age 18 years and older. If Twinrix is not available or if y'all choose not to utilise Twinrix to complete the Twinrix series, y'all should do the following: If 1 dose of Twinrix was given, complete the series with 2 adult doses of hepatitis B vaccine and 2 adult doses of hepatitis A vaccine. If 2 doses of Twinrix were given, consummate the schedule with 1 developed dose of hepatitis A vaccine and one 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 exist substituted for any dose of the hepatitis B series but not for whatsoever dose of the hepatitis A series.

• Whatever combination of 3 doses of adult hepatitis B or 3 doses of Twinrix is a complete series of hepatitis B vaccine. • One dose of Twinrix + 2 doses of adult hepatitis A is a consummate series of hepatitis A vaccine. • Two doses of Twinrix + 1 dose of adult hepatitis A is a complete serial of hepatitis A vaccine.

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

No. Twinrix contains l% less hepatitis A antigen component than Havrix, GSK'due south monovalent hepatitis A vaccine [720 vs. 1440 El. U.], and then the patient would not receive the recommended dose of hepatitis A vaccine antigen. For this reason, 3 doses of Twinrix must contain the serial.

Allowed Globulin Back to top

What is immune globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile preparation of concentrated antibodies (i.e., immunoglobulins) made from pooled human plasma processed by cold ethanol fractionation. GamaSTAN is the only IG product licensed in the Usa for the prevention of hepatitis A. Only plasma that has tested negative for hepatitis B surface antigen, antibody to human immunodeficiency virus (HIV), and antibiotic to hepatitis C virus (HCV) is used to produce IG. In addition, the Food and Drug Administration requires that the process used to produce IG include a viral inactivation pace or that final products test negative for HCV-RNA by polymerase chain reaction. Anti-HAV concentrations differ amongst IG lots and decreasing concentrations have been observed over the past xxx 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 2 months.

When administered for preexposure prophylaxis, a dose of 0.one mL/kg will provide protection for up to 1 calendar 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.ii mL/kg can exist repeated every 2 months. There is no maximum number of times the bimonthly doses of IG may exist 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 bachelor in single-use vials (2 mL and 10 mL). Information technology should be administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Do not apply the gluteal region as an injection site because of the risk of injury to the sciatic nervus.

Does IG cause adverse events?

Serious adverse events from GamaSTAN IG are rare. Anaphylaxis has been reported after repeated assistants to people with known immunoglobulin A (IgA) deficiency; thus, IG should not be administered to these people. IG products including GamaSTAN have been associated with the formation of claret clots (thrombosis) after administration, particularly if the patient has other risk factors for thrombosis. Patients should be counseled well-nigh this risk.

Can pregnant or lactating women receive IG?

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

A child in my exercise was given hepatitis A IG (GamaSTAN, Grifols) when she was 10 months old after her mother tested positive for hepatitis A. She'south scheduled for her 12-month-old well-child visit. Volition this bear on her vaccination schedule?

Yes. IG may be given whatsoever fourth dimension before or after inactivated vaccines. However, the antibodies in IG may interfere with the effectiveness of certain live-virus vaccines, such equally measles, mumps, and rubella (MMR) and varicella vaccines. CDC recommends waiting at to the lowest degree 6 months from the appointment of IG assistants before administering MMR and varicella vaccines.

Which people should become 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 (folio 19) and Appendices A and B of the 2022 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 age 6 months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver affliction vaccinated within 2 weeks of departure may consider IG in add-on to vaccination, based upon the clinician's take a chance assessment • Previously unvaccinated people who are immunocompromised may consider IG in addition to vaccination, regardless of the timing of vaccination, based upon the clinician's risk cess • Previously unvaccinated people who are over age forty years and vaccinated within 2 weeks of difference may consider IG in addition to vaccination, based upon the clinician'southward take a chance assessment

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

• Infants nether age 12 months • Previously unvaccinated immunocompromised adults (including HIV+), in addition to vaccination • Previously unvaccinated adults with chronic liver disease, in addition to vaccination • Previously unvaccinated adults over age 40 years, consider IG in add-on 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 elevation

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people historic period 6 months or older who are traveling to or working in an area of the globe at intermediate or high take chances of hepatitis A manual. Areas of low gamble include the Us, Canada, Nihon, New Zealand, Commonwealth of australia and Western Europe. Visit the CDC's Traveler Health website for more data most 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 electric 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 forty years who are planning travel to an area with high or intermediate HAV endemicity and have not received HepA vaccine should receive a unmarried dose of HepA vaccine as before long as travel is considered and should complete the 2-does series according to the routine schedule.

People with chronic liver disease as well every bit adults older than 40 years of age, immunocompromised persons, and persons with other chronic medical conditions planning to depart to an surface area with high or intermediate HAV endemicity in less than 2 weeks should receive the initial dose of HepA vaccine and may as well simultaneously be administered IG at a divide anatomic injection site (for example in split limbs).

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2022 to include vaccination of infants 6 through xi months of historic period. All infants of this historic period traveling internationally should be given a dose of measles, mumps, rubella vaccine (MMR) before travel. Due to the potential interference of hepatitis A immune globulin (IG) with MMR vaccine effectiveness, an off-label dose of HepA vaccine is recommended instead of IG in this situation. The travel-related dose for infants 6–eleven months of historic period should not be counted toward the routine 2-dose series. The routine 2-dose HepA and MMR vaccination series should exist initiated at age 12 months according to the routine, historic period-advisable vaccination schedule.

Infants younger than half dozen 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 1 month, a dose of 0.2 mL/kg should exist administered. A 0.2 mL/kg dose tin can be repeated every 2 months for travel of more than than ii months elapsing.

Can Twinrix exist used for people planning international travel?

Yes. If fourth dimension allows, use the standard Twinrix schedule of 3 doses given intramuscularly on a 0, 1, and vi month schedule. If travel is imminent the accelerated 4-dose Twinrix schedule can be used, which is 3 doses given on days 0, 7, and 21-30 days and a booster dose at 12 months.

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

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

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

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

If a traveler received the commencement dose of HepA vaccine more than 1 year ago and needs to travel abroad imminently, volition the traveler need IG in add-on to dose #2 prior to leaving?

No. Simply requite the terminal dose of HepA vaccine prior to travel.

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

Possibly. Since IG protects against HAV infection for only 1 to 2 months, depending on the dosage given, boosted IG may be needed if the infant is not yet age 6 months. In one case the child has reached six months of age, HepA vaccine should exist given.

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

Yeah. ACIP recommends that all children age ane twelvemonth through 18 years should exist vaccinated confronting hepatitis A. VFC HepA vaccine may be administered to any eligible child, including those recommended for vaccination at vi through xi months of age every bit a outcome of travel to an HAV-endemic area.

If a person was born and grew upwards in a country where HAV infection is owned (e.k., Vietnam, United mexican states) and then moved to the United States at age twenty, should that person receive HepA vaccine before returning to visit his/her homeland?

It depends on whether that person has a history of HAV infection. Unless there are medical records that document prior HAV infection, serologic testing for immunity (positive test for total anti-HAV) is the only style to decide if vaccination is necessary. For people from countries with high rates of HAV infection, such every bit Vietnam and Mexico, serologic testing might be washed to forbid unnecessary vaccination. The toll effectiveness of serologic testing, nevertheless, should exist balanced confronting the possibility of delaying needed vaccination while awaiting test results.

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

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

Vaccine Safety Back to top

What reactions might occur later on administration of HepA vaccine?

No serious agin events accept been attributed definitively to HepA vaccine. Among adults, the most frequently reported side effects are soreness at the site of the injection and headache. In children, the most frequently reported side issue is soreness at the injection site. The frequency of side effects afterwards 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. As with all other vaccines, in that location is a precaution when giving it to anyone who is moderately or severely ill.

Can significant women receive HepA vaccine?

Yes. ACIP recommends that pregnant women at take chances for HAV infection during pregnancy or at run a risk for a severe outcome from HAV infection should be vaccinated during pregnancy if not previously vaccinated. Pregnant women should be vaccinated for the aforementioned indications as not-significant women. For additional details, run across folio 20 of the electric 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 damage to the nursing infant.

Can HepA vaccine be given to immunocompromised people?

Yes. All people historic period 1 twelvemonth or older living with HIV infection should be vaccinated against hepatitis A if they have not been vaccinated, regardless of their CD4+ count.

If whatsoever immunocompromised person has a gamble gene that places them at increased risk 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 want to give him HepA vaccine. Is it 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 refrigerator temperature at 2°C to eight°C (36°F to 46°F). The vaccine must not be frozen. Any vaccine exposed to freezing temperature should not be used. Practise not employ these or any other vaccines subsequently the expiration appointment shown on the packaging. Any vaccine administered after its expiration date is non valid and should be repeated.

Dorsum to top

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Source: https://www.immunize.org/askexperts/experts_hepa.asp#:~:text=Once%20you%20have%20had%20HAV,you%20cannot%20get%20it%20again.&text=What%20is%20the%20best%20way,way%20to%20prevent%20HAV%20infection.

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