What Is the Soonest a Baby Can Get a Hep a Vaccine

Hepatitis A

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Disease Issues

What is hepatitis A?

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

What are the signs and symptoms of hepatitis A?

Disease acquired past HAV infection cannot exist distinguished from other types of acute viral hepatitis, just information technology 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 vi years, 70% of infections are asymptomatic. When disease does occur in young children, information technology is typically not accompanied by jaundice. In older children and adults, infection typically is symptomatic, with jaundice occurring in more than seventy% of patients.

Hepatitis A signs and symptoms usually resolve in 2-three months, although 10% to 15% of symptomatic people have prolonged disease (unremarkably referred to as relapsing hepatitis A) lasting up to six months and should exist considered infectious during that fourth dimension.

How is HAV transmitted?

Person-to-person spread through the fecal-oral route is the principal 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 most people are no longer infectious one week after jaundice onset. Earlier routine vaccination of children was recommended, children were a cardinal source of infection because most infected children had no symptoms and could shed virus in stool for weeks or months. Manual currently occurs primarily amongst susceptible adults.

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

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

What is the incubation period for hepatitis A?

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

How is HAV shed?

In infected people, HAV replicates in the liver, is excreted in bile, and is shed in stool. Peak infectivity occurs during the 2-week period before onset of jaundice or superlative of liver enzymes, when concentration of virus in stool is highest. Concentration of virus in stool declines after jaundice appears, with almost people no longer infectious virtually a week subsequently jaundice appears. Children can shed HAV for longer periods than adults, upwardly to 10 weeks or longer after onset of clinical illness.

How common is HAV infection in the United States?

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

Between 2012 and 2015 the number of reported hepatitis A infections ranged from approximately 1200 to 1800 cases every year. Beginning in 2016, large foodborne outbreaks led to an increase in the number of cases and sustained, big person-to-person outbreaks began, primarily driven by infections among unvaccinated people who apply drugs and people experiencing homelessness and their contacts. Since 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 data regarding ongoing multistate outbreaks tin can be found here: world wide web.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Practise people dice from hepatitis A?

Yes. Decease as a result of fulminant hepatic failure is rare, however, older age (over 40 years) and preexisting chronic liver disease increases the risk of astringent disease and expiry from hepatitis A. The person-to-person U.South. multistate outbreaks that began in 2016 have disproportionately affected adults with chronic liver illness and other health problems related to drug utilize and unstable housing. From 2016 through November 2021, CDC received reports of about 43,000 cases of acute HAV infection. Of these, approximately 61% have been hospitalized and 1% (more than 400 people) accept died.

Who is about at risk for acquiring HAV infection?

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

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

I thought people with clotting factor disorders were at risk for hepatitis A due to their regular use of blood products. Why did ACIP decide to finish 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 time, the process used to brand clotting factor supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of HAV infection. Modernistic blood donor screening and virus reduction steps have drastically reduced that take a chance. In addition, more than fourscore% of people with clotting cistron disorders now receive recombinant clotting factor concentrates that are sterilized and accept no risk of HAV transmission. Every bit a consequence 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 information technology is otherwise indicated.

Are people with developmental disabilities at take chances of HAV infection?

Historically, HAV infection was highly endemic in institutions for people with developmental disabilities as a result of poor manus hygiene, close living conditions and diaper use. As fewer children have been institutionalized and as conditions in institutions have improved, the incidence and prevalence of HAV infection have decreased, although outbreaks tin occur in these settings. All children with developmental disabilities should receive HepA according to U.S. routine vaccine recommendations, including catch upward vaccination of all children through historic period eighteen years.

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

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

No. People with chronic liver disease are not at increased gamble for acquiring HAV infection. Withal, they are at an increased risk for life-threatening, fulminant (astringent and sudden) hepatitis if they become infected with hepatitis A. People considered to take chronic liver disease include those with hepatitis B or C infection, cirrhosis, fat liver affliction, alcoholic liver disease, and autoimmune hepatitis.

Please hash out the tests ordinarily used to diagnose hepatitis A.

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

• Anti-HAV: Full antibody to HAV. This diagnostic examination detects full antibody of both IgG and IgM subclasses of HAV. If positive, it indicates either acute or resolved infection. • IgG anti-HAV: IgG antibody is a bracket of anti-HAV. It appears early on in the grade of infection, remains detectable for the person'southward lifetime and provides lifelong protection confronting 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). Information technology is used to diagnose acute (recently acquired) hepatitis A. Because of the chance of imitation positive IgM anti-HAV results, people should but exist tested for IgM anti-HAV if they are symptomatic and suspected of having astute hepatitis A illness. • HAV RNA tests too may be used to diagnose acute infection through the direct detection of viral RNA in serum or stool.

Total anti-HAV, which appears early on in the course 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 v to 10 days before onset of symptoms and lasts about vi months. However, in that location accept been reports of persons who exam 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 bachelor on the CDC website at www.cdc.gov/hepatitis/resources/professionals/training/serology/preparation.htm.

Tin can HAV be transmitted by blood?

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

Is HAV transmitted past saliva?

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

How mutual is HAV manual in hospital settings?

Hospital-caused HAV infection is rare. In the past, outbreaks were observed in neonatal intensive intendance units when infants acquired infection from HAV-infected transfused blood and subsequently transmitted HAV to other infants and staff. Outbreaks of hepatitis A caused by transmission from adult patients to healthcare personnel (HCP) are typically associated with fecal incontinence and inadequate manus hygiene, although the bulk of hospitalized patients who have hepatitis A are admitted later on onset of jaundice, when they are across the point of peak infectivity. Transmission in healthcare settings likewise has resulted from breakdowns in standard infection control practices and transmission from one healthcare provider to another.

How stable is HAV in the environment?

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

Adequately chlorinating water through water handling processes and dilution in public water systems kills HAV. Spas and pond 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 get repeated infections?

No, there is no chronic (long-term) infection. Fifty-fifty the small-scale proportion of people who develop relapsing HAV recover after about half dozen months. Once you have had HAV infection and recovered, y'all cannot get information technology again.

Vaccination Recommendations Back to top

What is the best way to prevent HAV infection?

Vaccination with the full series of hepatitis A vaccine (HepA) is the all-time way to forbid HAV infection. Immune globulin (IG) also tin 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 of america?

Recommended dosages and schedules of hepatitis A vaccines Vaccine Historic period group Dose Volume # Doses Schedule Havrix (GSK) 1-xviii years 720 El.U.* 0.5 ml two 0, vi-12 mos. 19 years and older 1440 El.U.* i.0 ml ii 0, half dozen-12 mos. Vaqta (Merck & Co.) one-xviii years 25 U** 0.5 ml 2 0, 6-xviii mos. 19 years and older l U** i.0 ml 2 0, 6-eighteen 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 be used for rapid protection prior to travel or for rapid protection of an unexposed just at-risk person who also would benefit from hepatitis B protection. Twinrix is not recommended for use as mail-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

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

Where tin I detect information most vaccine shortages?

For detailed information well-nigh HepA shortages, become to CDC'due south website at www.cdc.gov/vaccines/hcp/clinical-resource/shortages.html.

Who is recommended to receive HepA vaccine?

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

• All children at age i twelvemonth (12–23 months) • All children and adolescents historic period two through eighteen years who take not previously received HepA should be vaccinated (i.e., routine catch-up 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 United states, Canada, Western Europe, Japan, New Zealand, and Australia. For more data, see the CDC travel health website for electric current information about specific countries at www.cdc.gov/travel or the CDC Yellow Volume (wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-a). When in uncertainty, vaccinate. • Infants age six through eleven months traveling outside the United states should receive i dose when protection confronting HAV infection is recommended. The travel dose does not count toward the routine HepA serial which should be initiated at age 1 twelvemonth with the appropriate dose and schedule. In these instances, the child will receive a total of iii doses of HepA vaccine. • Men who have sexual practice with men • Users of illegal drugs, injectable or noninjectable • People who are homeless or in unstable living arrangements, including shelters • Previously unvaccinated people who conceptualize having shut personal contact with an international adoptee from a country of high or intermediate endemicity during the first lx days following the adoptee's arrival 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 but non limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fat liver disease, alcoholic liver disease, autoimmune hepatitis, or an ALT or AST level persistently greater than twice the upper limit of normal) • People identified during pregnancy to exist at chance for HAV infection due to presence of a specific take chances gene for exposure or at risk for astringent outcome 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 take a chance for HAV infection or at risk for astringent disease from HAV • Any person who wishes to be immune to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, nutrient handlers, sewage workers, or mean solar day intendance providers because at that place is no evidence that their occupational risks of HAV exposure are significantly higher than the general population. All the same, whatever person who desires protection from HAV infection may be vaccinated.

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

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

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

Should nosotros give HepA to a person older than historic period xviii years who requests it?

Aye, unless the person is allergic to whatsoever of the vaccine components. HepA vaccination is rubber 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 two doses of HepA vaccine beginning at age ane twelvemonth (i.e., 12–23 months). The 2 doses in the series should be administered at least 6 months apart. Any kid historic period ii through 18 years non previously vaccinated should be vaccinated. For a copy of the ACIP recommendations on hepatitis A, go to www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

For hepatitis A vaccination, the minimum interval between the ii-dose series is at to the lowest degree six months. Is this the aforementioned equally 24 weeks?

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

I take a kid who was given her 2d dose of hepatitis A vaccine 4 months after the commencement dose. Does information technology need to be repeated, and if then, when?

Yes. The 2d dose was given more than 4 days before the minimum interval of six calendar months, then information technology is considered invalid and should be repeated. The echo dose should exist administered the proper minimum interval (half dozen months) later on the invalid dose. If this echo dose is inadvertently given less than 6 months after the invalid dose, it does non need to be repeated again as long as the interval betwixt the initial HepA vaccine and the most recent 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 see the complete PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attention to Table 4 on page nineteen and Appendix B: Provider Guidance on Gamble Assessment for Hepatitis A Postexposure Prophylaxis, beginning on page 36.

Healthy people who have completed the HepA vaccination serial at any time do not demand additional PEP if they are exposed to HAV. People who have recently been exposed to HAV and who have non 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 have not previously completed the HepA vaccine series should receive a single dose of HepA vaccine as shortly equally possible. In add-on to vaccine, allowed globulin (IG; 0.1 mL/kg) may exist administered to people older than age 40 years depending on the providers' risk assessment. For long-term amnesty, the HepA vaccine series should be completed with a second dose at least half-dozen months afterwards the first dose. Nonetheless, the second dose is not necessary for PEP. A second dose should not be administered sooner than 6 calendar months after the commencement dose, regardless of HAV exposure risk.

People age 12 months or older who are immunocompromised or accept chronic liver disease, and who have been exposed to HAV within the past fourteen days and accept not previously completed the HepA vaccination series, should receive both IG (0.ane mL/kg) and HepA vaccine at the same visit in a different anatomic site (for example, separate limbs) as soon as possible later on exposure. For long-term immunity, the HepA vaccination series should be completed with a second dose at least six months after the first dose. All the same, the second dose is not necessary for PEP. A second dose should not exist administered sooner than 6 calendar months after the first dose, regardless of HAV exposure chance.

People with HIV infection develop protective levels of antibody more slowly and are less probable to develop protective antibody levels after vaccination with HepA, especially if their CD4+ count is low at the fourth dimension of vaccination. Protection following vaccination of a person with HIV may wane over time. Vaccine should be administered if the exposed individual is not fully vaccinated; all the same, CDC also advises clinicians to consider administering IG PEP to an private with HIV later a loftier-risk 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 unmarried-dose adult HepA vaccine. Twinrix should non be used for PEP merely may be used to confer protection to at-run a risk but not yet exposed persons during an outbreak.

Infants younger than historic period 12 months and persons for whom vaccine is contraindicated should receive IG (0.1 mL/kg) instead of HepA vaccine as before long equally possible and within 2 weeks of exposure. MMR and varicella vaccines should not be administered sooner than 6 months after IG administration in social 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 not indicated for children because of the low prevalence of infection in children. It also is not routinely recommended for adults but may be considered in some settings to reduce costs associated with vaccinating people who are already immune. Prevaccination testing should not be used if it poses a bulwark to vaccinating susceptible people, especially people who are hard to access.

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

When should postvaccination testing be performed?

Serologic testing for immunity is not necessary after routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibody 1 calendar month or more later on completing the HepA vaccination serial is recommended only for people whose future clinical management depends on knowing their immune condition and for whom revaccination might be indicated, such equally people living with HIV and other immunocompromised persons (such as transplant recipients and people vaccinated while receiving chemotherapy). In such individuals, if the results of postvaccination testing exercise not show an adequate immune response (10 mIU/mL or higher), revaccination with a consummate serial is recommended, followed by a second postvaccination serologic exam. If that second examination remains negative, no additional vaccination is recommended; however, the patient should exist counseled on strategies to avoid exposure to HAV and the need for IG if an exposure occurs. If vaccination results in seroconversion, bereft data are available to make recommendations concerning echo testing, booster doses or revaccination.

For Special Groups Back to acme

Explicate the details regarding the recommendation for giving HepA vaccine to people who will exist 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 following the adoptee's inflow in the U.Southward. In addition to the adoptee'south new parents and siblings, this group might include grandparents, other household members, regular babysitters and other caregivers. The outset dose of HepA should be given to close contacts equally presently as adoption is planned, ideally at to the lowest degree two weeks before the arrival of the adoptee. A 2nd dose should exist given no sooner than 6 months after the first dose.

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

The 2020 ACIP recommendations for the prevention of hepatitis A define a person experiencing homelessness as 1) a person who lacks housing (regardless of whether the person is a fellow member of a family), including a person whose chief residence during the dark 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: live on the streets, stay in a shelter, mission, single-room occupancy facility, abased edifice, vehicle, or any other unstable or nonpermanent situation, or 3) who is "doubled up", a term that refers to a situation where persons are unable to maintain their housing situation and are forced to stay with a series of friends or extended family unit members. In addition, previously homeless persons who are to be released from a prison or a hospital might exist considered homeless if they do not have a stable housing situation to which they can return. The instability of a person's living arrangements is critical to the definition of homelessness.

Some people on my team are worried about initiating the HepA vaccine serial in people who are homeless considering nosotros may not exist able to complete the serial or keep upwards with their records over time. How much of a business concern is this?

While a complete series of HepA is recommended for long-term protection, even a unmarried dose of HepA vaccine has been demonstrated to provide protection confronting hepatitis A for more than 10 years and can preclude or control outbreaks of hepatitis A. People who are experiencing homelessness may have difficulty protecting themselves from exposure to HAV in other ways because of their living conditions. They should be vaccinated when possible and provided a record of immunization. Reporting the HepA vaccination to a state immunization information organisation as well can facilitate immunization assessment at future healthcare encounters.

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

No. A number of studies have shown that HCP are not at significantly increased risk of HAV infection because of their occupation. However, if HCPs are going to work (or holiday) in a country with a loftier or intermediate endemic rate of HAV infection, they are at risk of HAV infection and should exist 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 against hepatitis A?

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

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

Although non at increased hazard 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 amid United states wastewater workers and appropriate comparing populations, no substantial or consistent increase in the prevalence of anti-HAV was identified among wastewater workers. No piece of work-related instances of HAV manual have been reported among wastewater workers in the The states. In addition, in the United States, outbreaks of hepatitis A caused by flooding, which can acquit raw sewage, take 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 risk of HAV infection. Modern claret donor screening and virus reduction steps have drastically reduced that run a risk. In add-on, more than 80% of people with clotting cistron disorders now receive recombinant clotting factor concentrates that are sterilized and have no adventure of HAV transmission. As a result of these factors, people with clotting factor disorders now accept 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 not recommended) for infant travelers age 6 through 11 months at hazard of exposure to HAV?

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

The antibodies in immune globulin (IG) typically used to prevent HAV infection in infants earlier the first altogether tin 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 6 months after IG administration. If an baby 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 (non IG) in improver to MMR. The HepA and MMR doses administered before the showtime birthday do non 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 historic period appropriate.

Tin can significant women receive hepatitis A vaccine?

Aye. The ACIP recommends that pregnant women at risk for HAV infection during pregnancy or at risk for a severe upshot from HAV infection should exist vaccinated during pregnancy if non previously vaccinated. Pregnant women should exist vaccinated for the same indications as non-pregnant women. For additional data, see page twenty of the recommendations: world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Administering Vaccines Back to meridian

By 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 age and torso mass.

Can HepA vaccine be given concurrently with other vaccines?

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

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

Yes, VFC-supported HepA vaccine is available for children 12 months through 18 years who are VFC-eligible. In add-on, 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 practice not need to start the serial over again. The immunogenicity of ane 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-twelvemonth-erstwhile patient's HepA vaccine serial, how many adult doses should I give if the patient received a single dose of pediatric HepA vaccine v years agone?

A person should receive the dosage of HepA vaccine appropriate for their age at the time of administration. You should requite the patient one adult dose of HepA to consummate the 2-dose series. Information technology is not necessary to restart the vaccine serial.

Ane of our staff gave a dose of pediatric HepA vaccine to an developed patient by mistake. How exercise we remedy this error?

In general, if the error is discovered on the aforementioned dispensary 24-hour interval, you lot can administer the other "half" of the dose on that same day. If the mistake is discovered later, the dose should not be counted, and and then the person should be recalled to the part and given a total age-appropriate repeat dose.

If yous give more than than an historic period-appropriate dose (for case, an adult dose of HepA vaccine given to a kid), count the dose as valid and notify the patient/parent most the fault. There may be an increased risk of a local adverse reaction when more than the recommended dose is given. If the error occurred with the first dose of the serial the child should yet receive the second dose on schedule. Giving a "double" dose for the first dose does not negate the demand for a second dose.

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

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

The efficacy data from the clinical trials were based on age at time of vaccination, and non on the weight of the individual. Hence, the dosage recommendations reflect this historic period-based efficacy data. The same holds true for HepB vaccine. In add-on, higher response rates are expected in younger people, even if their weights are above the norm.

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

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

In the U.Due south., Twinrix is licensed for utilise in people who are age 18 years or older. Information technology 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. Primary immunization consists of 3 doses given intramuscularly on a 0, 1, and half-dozen month schedule. In 2007, the FDA also canonical a iv-dose schedule for Twinrix. Information technology consists of 3 doses given inside 4 weeks, followed by a booster dose at 12 months (0, seven days, 21–30 days, and 12 months). The 4-dose schedule could do good individuals needing rapid protection from hepatitis A and hepatitis B, such as people traveling to high-prevalence areas imminently.

Twinrix cannot be used for postexposure prophylaxis.

I have seen adults who take had ane or two doses of Twinrix, merely we only carry single-antigen vaccine in our exercise. How should we complete their vaccination serial with single-antigen vaccines?

Twinrix is licensed as a 3-dose series for people historic period 18 years and older. If Twinrix is not bachelor or if you choose not to use Twinrix to complete the Twinrix serial, you should practise the following: If one 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, complete the schedule with 1 adult dose of hepatitis A vaccine and 1 adult dose of hepatitis B vaccine.

Some other way to consider this is equally follows:

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

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

We're thinking of using Twinrix and we're wondering whether nosotros tin use information technology for doses #i and #three simply and utilize single antigen hepatitis B vaccine for dose #2?

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

Immune 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 The states for the prevention of hepatitis A. Only plasma that has tested negative for hepatitis B surface antigen, antibody to man immunodeficiency virus (HIV), and antibody to hepatitis C virus (HCV) is used to produce IG. In addition, the Nutrient and Drug Administration requires that the process used to produce IG include a viral inactivation stride or that terminal products test negative for HCV-RNA by polymerase chain reaction. Anti-HAV concentrations differ amid IG lots and decreasing concentrations accept been observed over the past 30 years, probably because of the decreasing prevalence of previous HAV infection amid plasma donors. In 2017, the dosing of GamaSTAN for HAV prevention was increased to reflect this change in anti-HAV authority.

How does allowed globulin (IG) work?

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

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

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

How is IG packaged and how is IG administered?

Intramuscular IG is bachelor in single-utilize vials (ii mL and x mL). It should exist administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Do not utilize 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 administration to people with known immunoglobulin A (IgA) deficiency; thus, IG should not be administered to these people. IG products including GamaSTAN have been associated with the formation of blood clots (thrombosis) afterward administration, particularly if the patient has other risk factors for thrombosis. Patients should exist counseled most this risk.

Tin meaning or lactating women receive IG?

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

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

Yes. IG may exist given whatever time before or after inactivated vaccines. However, the antibodies in IG may interfere with the effectiveness of certain alive-virus vaccines, such as measles, mumps, and rubella (MMR) and varicella vaccines. CDC recommends waiting at least 6 months from the date of IG assistants before administering MMR and varicella vaccines.

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

Please see details of the recommendations for the use of IG for the prevention of hepatitis A provided in Table 4 (page 19) and Appendices A and B of the 2020 ACIP recommendations for the prevention of hepatitis A infection: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Below is a cursory summary of the recommendations:

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

• Infants younger than historic period vi months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver disease vaccinated within 2 weeks of departure may consider IG in addition to vaccination, based upon the clinician'south gamble assessment • Previously unvaccinated people who are immunocompromised may consider IG in addition to vaccination, regardless of the timing of vaccination, based upon the clinician'south risk assessment • Previously unvaccinated people who are over age 40 years and vaccinated within 2 weeks of departure may consider IG in improver to vaccination, based upon the clinician's adventure assessment

Postexposure prophylaxis with IG inside 2 weeks after 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 illness, in add-on to vaccination • Previously unvaccinated adults over age xl years, consider IG in add-on to vaccination, based upon clinician risk assessment • People with HIV infection, previously vaccinated, consider IG following a high-chance exposure (household or sexual contact), based upon clinician run a risk assessment

Travel - International Back to top

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people age 6 months or older who are traveling to or working in an area of the globe at intermediate or loftier adventure of hepatitis A transmission. Areas of low risk include the United States, Canada, Nihon, New Zealand, Australia and Western Europe. Visit the CDC's Traveler Health website for more than 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 40 years who are planning travel to an area with high or intermediate HAV endemicity and take not received HepA vaccine should receive a single dose of HepA vaccine every bit soon as travel is considered and should complete the 2-does series co-ordinate to the routine schedule.

People with chronic liver disease too as adults older than forty years of historic period, immunocompromised persons, and persons with other chronic medical weather condition planning to depart to an area with high or intermediate HAV endemicity in less than ii weeks should receive the initial dose of HepA vaccine and may also simultaneously be administered IG at a separate anatomic injection site (for example in separate limbs).

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2018 to include vaccination of infants 6 through xi months of age. All infants of this historic period 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-label dose of HepA vaccine is recommended instead of IG in this situation. The travel-related dose for infants 6–11 months of age should not exist counted toward the routine ii-dose serial. The routine 2-dose HepA and MMR vaccination series should be initiated at age 12 months according to the routine, age-advisable vaccination schedule.

Infants younger than 6 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 than ane calendar month, a dose of 0.2 mL/kg should be administered. A 0.ii mL/kg dose tin can be repeated every 2 months for travel of more 2 months duration.

Tin Twinrix exist used for people planning international travel?

Yeah. If time allows, utilize 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 tin can be used, which is three doses given on days 0, 7, and 21-30 days and a booster dose at 12 months.

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

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

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

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

If a traveler received the first dose of HepA vaccine more i twelvemonth agone and needs to travel abroad imminently, volition the traveler need IG in addition to dose #two prior to leaving?

No. But give the concluding dose of HepA vaccine prior to travel.

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

Mayhap. Since IG protects against HAV infection for only 1 to 2 months, depending on the dosage given, additional IG may exist needed if the infant is not yet age 6 months. One time the child has reached half-dozen months of age, HepA vaccine should exist given.

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

Yes. ACIP recommends that all children age ane year through 18 years should be vaccinated against hepatitis A. VFC HepA vaccine may be administered to any eligible kid, including those recommended for vaccination at 6 through 11 months of age every bit a result of travel to an HAV-owned surface area.

If a person was built-in and grew upwardly in a country where HAV infection is endemic (eastward.g., Vietnam, Mexico) and then moved to the United states of america at historic period xx, 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 certificate prior HAV infection, serologic testing for amnesty (positive test for full anti-HAV) is the only way to determine if vaccination is necessary. For people from countries with high rates of HAV infection, such as Vietnam and United mexican states, serologic testing might be done to forbid unnecessary vaccination. The toll effectiveness of serologic testing, nevertheless, should be balanced confronting the possibility of delaying needed vaccination while awaiting test results.

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

No, as long as there are medical records that certificate that the person was previously infected with HAV (i.east., positive examination 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 non harm a person who is already immune.

Vaccine Condom Dorsum to top

What reactions might occur after administration of HepA vaccine?

No serious adverse 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 about often reported side outcome is soreness at the injection site. The frequency of side effects subsequently administration of Twinrix is like to those reported when the two 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 severe allergic reaction to a previous dose of HepA vaccine or to a vaccine component. Every bit with all other vaccines, there is a precaution when giving it to anyone who is moderately or severely ill.

Can pregnant women receive HepA vaccine?

Yes. ACIP recommends that significant women at take a chance for HAV infection during pregnancy or at risk for a severe effect from HAV infection should be vaccinated during pregnancy if non previously vaccinated. Pregnant women should exist vaccinated for the same indications as non-meaning women. For boosted details, run into folio 20 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.

Can HepA vaccine be given to immunocompromised people?

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

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

I have a patient on interferon for hepatitis C, merely 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 Treatment

How should HepA vaccine exist stored?

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

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

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