If I Had a Hep a Shot 15 Years Ago Do I Need a Booster if Going to Mexico Again

Hepatitis A

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Illness Issues

What is hepatitis A?

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

What are the signs and symptoms of hepatitis A?

Illness caused by HAV infection cannot be distinguished from other types of astute viral hepatitis, but it typically has an abrupt onset that can include fever, malaise, anorexia, nausea, abdominal discomfort, night urine, and jaundice. The likelihood of having symptoms with HAV infection is related to age. In children younger than age 6 years, 70% of infections are asymptomatic. When disease does occur in immature children, it is typically not accompanied by jaundice. In older children and adults, infection typically is symptomatic, with jaundice occurring in more than 70% of patients.

Hepatitis A signs and symptoms usually resolve in 2-3 months, although 10% to 15% of symptomatic people have prolonged illness (usually referred to every bit relapsing hepatitis A) lasting upwards to half-dozen months and should exist considered infectious during that time.

How is HAV transmitted?

Person-to-person spread through the fecal-oral road is the primary means of HAV transmission. Peak infectivity in infected people occurs during the two week catamenia earlier the onset of jaundice when the concentration of virus in the stool is highest and most people are no longer infectious one week afterward jaundice onset. Earlier routine vaccination of children was recommended, children were a key source of infection because nearly infected children had no symptoms and could shed virus in stool for weeks or months. Transmission currently occurs primarily among susceptible adults.

Mutual-source outbreaks and sporadic cases can occur from exposure to fecally-contaminated nutrient or water. Uncooked HAV-contaminated foods have been recognized as a source of outbreaks. Cooked foods likewise can transmit HAV if the temperature during nutrient preparation is inadequate to impale the virus or if food is contaminated after cooking, equally occurs in outbreaks associated with infected food handlers. Transmission of the virus from infected food handlers to food service institution 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 by occasional outbreaks, oft linked to viral contamination of imported food. Since 2017, communitywide outbreaks accept occurred more oftentimes, predominantly amid people who are continued by specific risk factors, such as drug utilize, and their close contacts.

What is the incubation period for hepatitis A?

HAV tin can produce either asymptomatic or symptomatic infection in humans later an boilerplate incubation menstruum of 28 days (range: fifteen–l days).

How is HAV shed?

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

How common is HAV infection in the United States?

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

Between 2012 and 2015 the number of reported hepatitis A infections ranged from approximately 1200 to 1800 cases every year. Starting time 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 use drugs and people experiencing homelessness and their contacts. Since and then, persistent person-to-person outbreaks have led to substantial increases in hepatitis A infection, with reported cases increasing past over 50% from 2018 to 2019. More information regarding ongoing multistate outbreaks can be constitute here: www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Practice people die from hepatitis A?

Yes. Death equally a effect of fulminant hepatic failure is rare, notwithstanding, older age (over forty years) and preexisting chronic liver affliction increases the adventure of severe disease and death from hepatitis A. The person-to-person U.S. multistate outbreaks that began in 2016 have disproportionately affected adults with chronic liver disease and other health problems related to drug use and unstable housing. From 2016 through November 2021, CDC received reports of near 43,000 cases of acute HAV infection. Of these, approximately 61% have been hospitalized and 1% (more 400 people) have died.

Who is nigh at adventure for acquiring HAV infection?

People who are at increased risk for acquiring HAV infection include the following:

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

I thought people with clotting gene disorders were at risk for hepatitis A due to their regular use of blood products. Why did ACIP make up one's mind to finish recommending routine vaccination of people with clotting cistron 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. Modern blood donor screening and virus reduction steps take drastically reduced that risk. In addition, more than 80% of people with clotting gene disorders at present receive recombinant clotting cistron concentrates that are sterilized and have no risk of HAV transmission. As a result of these factors, people with clotting factor 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 take a chance of HAV infection?

Historically, HAV infection was highly endemic in institutions for people with developmental disabilities as a result of poor mitt hygiene, close living conditions and diaper utilize. Equally fewer children have been institutionalized and as conditions in institutions accept 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 co-ordinate to U.South. routine vaccine recommendations, including take hold of up vaccination of all children through historic period 18 years.

As a strategy to further reduce the hazard of hepatitis A outbreaks and attain adults in settings with a high proportion of people with run a risk factors for HAV infection, the current ACIP recommendations propose because HepA vaccination of residents and staff in facilities where hygiene is difficult to maintain, such as grouping homes for people with developmental disabilities and homeless shelters.

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

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

Please discuss the tests ordinarily 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 antibiotic 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 grade of infection, remains detectable for the person's lifetime and provides lifelong protection confronting disease. Its presence indicates amnesty through either HAV infection or HepA vaccination. • IgM anti-HAV: IgM antibiotic is a subclass of anti-HAV. Its presence indicates a recent infection with HAV (6 months or less). Information technology is used to diagnose acute (recently acquired) hepatitis A. Because of the run a risk of false positive IgM anti-HAV results, people should just be tested for IgM anti-HAV if they are symptomatic and suspected of having acute hepatitis A illness. • HAV RNA tests also may exist used to diagnose astute infection through the direct detection of viral RNA in serum or stool.

Total anti-HAV, which appears early in the course of infection, remains detectable for the person's lifetime and indicates lifelong protection against the infection/disease. To confirm a diagnosis of acute HAV infection, serologic testing for IgM anti-HAV is required. In the bulk of persons, serum IgM anti-HAV becomes detectable 5 to 10 days before onset of symptoms and lasts about 6 months. Withal, at that place take been reports of persons who exam positive for IgM anti-HAV for upwardly to a yr or more following infection. An educational program on the interpretation of hepatitis A serology is available on the CDC website at www.cdc.gov/hepatitis/resource/professionals/training/serology/grooming.htm.

Tin HAV be transmitted by claret?

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

Is HAV transmitted past saliva?

In experimentally infected nonhuman primates, HAV has been detected in saliva during the incubation period; however, transmission by human saliva has non been reported.

How common is HAV transmission in hospital settings?

Hospital-acquired HAV infection is rare. In the by, outbreaks were observed in neonatal intensive care units when infants acquired infection from HAV-infected transfused blood and afterward 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 mitt hygiene, although the majority of hospitalized patients who have hepatitis A are admitted after onset of jaundice, when they are across the point of elevation infectivity. Transmission in healthcare settings also has resulted from breakdowns in standard infection control practices and manual from 1 healthcare provider to some other.

How stable is HAV in the environment?

Depending on conditions, HAV can be stable in the surroundings for months; freezing does non inactivate (i.due east., render non-infectious) HAV. HAV is inactivated past heating foods to temperatures greater than 185°F (85°C) for 1 minute. In addition, HAV on surfaces is inactivated by disinfecting surfaces with a 1:100 dilution of sodium hypochlorite (i.e., household bleach) in tap h2o.

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

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

No, in that location is no chronic (long-term) infection. Even the small proportion of people who develop relapsing HAV recover after nearly 6 months. One time you lot have had HAV infection and recovered, you cannot get information technology again.

Vaccination Recommendations Dorsum to top

What is the best fashion to prevent HAV infection?

Vaccination with the full serial of hepatitis A vaccine (HepA) is the best manner to prevent HAV infection. Immune globulin (IG) also can exist used for brusque-term protection in certain situations.

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

Recommended dosages and schedules of hepatitis A vaccines Vaccine Age group Dose Book # Doses Schedule Havrix (GSK) 1-18 years 720 El.U.* 0.5 ml ii 0, half-dozen-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 2 0, six-18 mos. xix years and older 50 U** 1.0 ml ii 0, 6-xviii mos.

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

Combination vaccine using hepatitis A and hepatitis B vaccines Vaccine Age group Antigens used Book # Doses Schedule Twinrix (GSK) 18 years and older Havrix (720 El.U.) combined with Engerix-B (20 mcg) 1.0 ml three 0, 1, 6 mos. iv 0, 7, 21-thirty days, 12 months***

*** Accelerated schedule may be used for rapid protection prior to travel or for rapid protection of an unexposed but at-risk person who also would do good from hepatitis B protection. Twinrix is not recommended for use as post-exposure prophylaxis.

Are HepA vaccine brands interchangeable?

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

Where tin I find information about vaccine shortages?

For detailed information about HepA shortages, go to CDC'south 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 post-obit groups:

• All children at age one year (12–23 months) • All children and adolescents historic period 2 through 18 years who have non previously received HepA should exist vaccinated (i.eastward., routine catch-up vaccination) [2020] • People living with HIV infection [2020] • Travelers historic period 12 months and older to areas of the world with intermediate or high HAV endemicity. Depression endemicity regions include the United States, Canada, Western Europe, Japan, New Zealand, and Australia. For more data, encounter the CDC travel health website for electric current information about specific countries at www.cdc.gov/travel or the CDC Yellowish Book (wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-a). When in doubt, vaccinate. • Infants age half dozen through 11 months traveling exterior the U.s. should receive 1 dose when protection against HAV infection is recommended. The travel dose does not count toward the routine HepA series which should be initiated at age 1 year with the appropriate dose and schedule. In these instances, the child will receive a total of 3 doses of HepA vaccine. • Men who have 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 shut personal contact with an international adoptee from a country of high or intermediate endemicity during the first threescore days post-obit 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 illness (including but not limited to people with hepatitis B infection, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or an ALT or AST level persistently greater than twice the upper limit of normal) • People identified during pregnancy to be at risk for HAV infection due to presence of a specific hazard factor for exposure or at adventure for severe outcome from HAV infection (for case, those with chronic liver disease or with HIV infection). • During an outbreak, whatsoever unvaccinated person who is identified equally at run a risk for HAV infection or at risk for severe 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 care providers because in that location is no prove that their occupational risks of HAV exposure are significantly college than the general population. Still, any person who desires protection from HAV infection may be vaccinated.

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

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

• [added] All children ages 2 through 18 years non previously vaccinated • [added] All people age 1 year or older living with HIV infection • [added] People identified to exist at risk for HAV infection during pregnancy • [removed] People with clotting cistron disorders

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

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

Which children should exist routinely vaccinated confronting HAV infection?

All children should receive 2 doses of HepA vaccine starting time at age 1 twelvemonth (i.eastward., 12–23 months). The 2 doses in the series should be administered at to the lowest degree vi months apart. Any child historic period two through 18 years not previously vaccinated should be vaccinated. For a copy of the ACIP recommendations on hepatitis A, become to world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

For hepatitis A vaccination, the minimum interval betwixt the 2-dose series is at to the lowest degree 6 months. Is this the same as 24 weeks?

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

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

Yep. The second dose was given more than than 4 days before the minimum interval of 6 agenda months, so it is considered invalid and should be repeated. The repeat dose should be administered the proper minimum interval (6 months) after the invalid dose. If this repeat dose is inadvertently given less than half-dozen months afterwards the invalid dose, it does non need to be repeated again as long equally the interval betwixt the initial HepA vaccine and the most recent dose is at to the lowest degree 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 meet the complete PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attention to Table iv on page 19 and Appendix B: Provider Guidance on Risk Assessment for Hepatitis A Postexposure Prophylaxis, beginning on page 36.

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

People historic period 12 months and older exposed to HAV inside the by fourteen days and who have not previously completed the HepA vaccine series should receive a single dose of HepA vaccine equally soon as possible. In addition to vaccine, immune globulin (IG; 0.i mL/kg) may be administered to people older than age forty years depending on the providers' risk assessment. For long-term amnesty, the HepA vaccine series should be completed with a 2nd dose at least six months subsequently the first dose. Even so, the second dose is not necessary for PEP. A 2d dose should not be administered sooner than 6 calendar months afterward the first dose, regardless of HAV exposure run a risk.

People age 12 months or older who are immunocompromised or take chronic liver illness, and who have been exposed to HAV within the past xiv days and have not previously completed the HepA vaccination series, should receive both IG (0.1 mL/kg) and HepA vaccine at the same visit in a different anatomic site (for example, separate limbs) as soon as possible after exposure. For long-term immunity, the HepA vaccination series should exist completed with a 2d dose at least 6 months after the first dose. However, the second dose is not necessary for PEP. A second dose should not exist administered sooner than 6 agenda months afterward the commencement dose, regardless of HAV exposure hazard.

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 time of vaccination. Protection post-obit vaccination of a person with HIV may wane over time. Vaccine should be administered if the exposed individual is non fully vaccinated; still, CDC likewise advises clinicians to consider administering IG PEP to an private with HIV after a high-take chances exposure (such as a household or sexual contact) even if the individual has been fully vaccinated.

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

Infants younger than age 12 months and persons for whom vaccine is contraindicated should receive IG (0.i mL/kg) instead of HepA vaccine as soon as possible and inside 2 weeks of exposure. MMR and varicella vaccines should not be administered sooner than half dozen months after IG administration in club to avert 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 considering 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 allowed. Prevaccination testing should non exist used if it poses a barrier to vaccinating susceptible people, peculiarly people who are hard to access.

Prevaccination testing is most likely to be cost-constructive for adults who were either born in or lived for long periods of time in areas of the earth 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 viable. If testing or vaccination history is not available, do non postpone vaccinating. There is no harm in vaccinating a person who has had natural infection or previous doses of vaccine.

When should postvaccination testing be performed?

Serologic testing for immunity is not necessary after routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibody one month or more after completing the HepA vaccination serial is recommended only for people whose future clinical direction 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 equally transplant recipients and people vaccinated while receiving chemotherapy). In such individuals, if the results of postvaccination testing do not show an adequate immune response (10 mIU/mL or higher), revaccination with a complete series is recommended, followed past a second postvaccination serologic test. If that second examination remains negative, no additional vaccination is recommended; all the same, 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 data are bachelor to make recommendations concerning repeat testing, booster doses or revaccination.

For Special Groups Back to summit

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

ACIP recommends vaccination against HAV infection for all previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of high or intermediate endemicity during the commencement 60 days following the adoptee's inflow in the U.S. In improver to the adoptee'south new parents and siblings, this group might include grandparents, other household members, regular babysitters and other caregivers. The showtime dose of HepA should exist given to close contacts as soon as adoption is planned, ideally at least 2 weeks before the arrival of the adoptee. A 2d dose should be given no sooner than vi months after the get-go dose.

ACIP at present recommends routine hepatitis A vaccination for people experiencing homelessness. Tin you provide a definition of "experiencing homelessness"?

The 2020 ACIP recommendations for the prevention of hepatitis A ascertain a person experiencing homelessness as ane) a person who lacks housing (regardless of whether the person is a member of a family unit), including a person whose primary residence during the 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 building, vehicle, or any other unstable or nonpermanent situation, or three) who is "doubled upwardly", a term that refers to a situation where persons are unable to maintain their housing situation and are forced to stay with a serial of friends or extended family members. In addition, previously homeless persons who are to exist released from a prison or a hospital might be considered homeless if they exercise non have a stable housing situation to which they tin render. 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 series in people who are homeless because we may not be able to complete the series or continue up with their records over time. How much of a concern is this?

While a consummate series of HepA is recommended for long-term protection, fifty-fifty a single dose of HepA vaccine has been demonstrated to provide protection against hepatitis A for more than 10 years and can forbid 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 system also tin 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 considering of their occupation. Yet, if HCPs are going to work (or vacation) in a country with a loftier 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-homo primates or alive HAV in a laboratory setting.

Should daycare workers be routinely vaccinated against hepatitis A?

No. In the past, outbreaks of hepatitis A occurred among children in child care centers, infecting employees of those centers, peculiarly those caring for infants and toddlers. Post-obit widespread adoption of early childhood vaccination against hepatitis A, outbreaks in child care centers are now rare.

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

Although not at increased hazard for HAV infection, people with chronic liver disease are at increased risk for fulminant hepatitis A, hospitalization and decease 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 amidst Usa wastewater workers and advisable comparing populations, no substantial or consistent increase in the prevalence of anti-HAV was identified among wastewater workers. No work-related instances of HAV transmission accept been reported among wastewater workers in the United States. In improver, in the U.s., outbreaks of hepatitis A acquired by flooding, which tin carry raw sewage, take not been reported.

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

People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that fourth dimension, the process used to make clotting factor supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of HAV infection. Modern blood donor screening and virus reduction steps have drastically reduced that risk. In addition, more than than 80% of people with clotting cistron disorders now receive recombinant clotting cistron concentrates that are sterilized and have no adventure of HAV manual. As a result of these factors, people with clotting cistron disorders now have no greater risk of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless it is otherwise indicated.

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

Because of measles. Measles is highly communicable and poses a serious threat to the 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 chance of measles infection during travel.

The antibodies in immune globulin (IG) typically used to prevent HAV infection in infants before 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 infant age 6 through xi months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-characterization apply of HepA vaccine (non IG) in add-on to MMR. The HepA and MMR doses administered before the first birthday practise not count toward the routine vaccination series of either vaccine: these infant travelers will withal need 2 doses of HepA and two doses of MMR when age appropriate.

Can pregnant women receive hepatitis A vaccine?

Yes. The ACIP recommends that meaning women at risk for HAV infection during pregnancy or at take chances for a astringent effect from HAV infection should be vaccinated during pregnancy if non previously vaccinated. Pregnant women should be vaccinated for the same indications as non-significant women. For additional data, meet 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 exist administered intramuscularly (IM), using the appropriate injection site and needle size every bit determined past the patient'due south age and torso mass.

Can HepA vaccine be given meantime with other vaccines?

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

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

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

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

You exercise not demand to start the series over once more. The immunogenicity of 1 dose of HepA vaccine is 94% to 100%; studies take shown persistent protection from a single dose lasting more than 10 years. To ensure optimal long-term protection it is important to administer the second dose.

To complete a 21-year-old patient'southward HepA vaccine series, how many adult doses should I requite if the patient received a single dose of pediatric HepA vaccine five years agone?

A person should receive the dosage of HepA vaccine appropriate for their historic period at the fourth dimension of administration. Y'all should give the patient ane developed dose of HepA to consummate the 2-dose serial. It is not necessary to restart the vaccine serial.

1 of our staff gave a dose of pediatric HepA vaccine to an adult patient by mistake. How exercise we remedy this fault?

In full general, if the mistake is discovered on the same clinic twenty-four hour period, you tin administrate the other "half" of the dose on that aforementioned day. If the error is discovered later, the dose should not be counted, and and then the person should be recalled to the role and given a total historic period-advisable repeat dose.

If you lot give more than than an age-appropriate dose (for example, an adult dose of HepA vaccine given to a child), count the dose equally valid and notify the patient/parent near the error. There may be an increased chance of a local adverse reaction when more the recommended dose is given. If the error occurred with the first dose of the series the child should still receive the 2d dose on schedule. Giving a "double" dose for the starting time dose does not negate the need for a 2nd dose.

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

Why does a xv yr 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 information 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 age-based efficacy information. The same holds true for HepB vaccine. In improver, higher response rates are expected in younger people, fifty-fifty if their weights are above the norm.

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

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

In the U.S., Twinrix is licensed for use in people who are age 18 years or older. Information technology can be administered to people who are at gamble 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 take sex with men, illegal drug users, or to people who simply want to be immune to both diseases. Chief immunization consists of 3 doses given intramuscularly on a 0, 1, and 6 month schedule. In 2007, the FDA also approved a 4-dose schedule for Twinrix. Information technology consists of 3 doses given within 4 weeks, followed past 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 high-prevalence areas imminently.

Twinrix cannot be used for postexposure prophylaxis.

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

Twinrix is licensed every bit a iii-dose series for people age 18 years and older. If Twinrix is non available or if you lot choose not to use Twinrix to complete the Twinrix series, you lot should do the following: If ane dose of Twinrix was given, complete the series with ii adult doses of hepatitis B vaccine and 2 adult doses of hepatitis A vaccine. If ii doses of Twinrix were given, complete the schedule with 1 adult dose of hepatitis A vaccine and 1 adult dose of hepatitis B vaccine.

Another fashion to consider this is as follows:

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

• Any combination of 3 doses of developed hepatitis B or three doses of Twinrix is a consummate series of hepatitis B vaccine. • One dose of Twinrix + 2 doses of developed hepatitis A is a complete series of hepatitis A vaccine. • Two doses of Twinrix + ane 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 only and utilize single antigen hepatitis B vaccine for dose #two?

No. Twinrix contains 50% less hepatitis A antigen component than Havrix, GSK's monovalent hepatitis A vaccine [720 vs. 1440 El. U.], so the patient would not receive the recommended dose of hepatitis A vaccine antigen. For this reason, three doses of Twinrix must comprise the series.

Allowed Globulin Back to height

What is immune globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile preparation of concentrated antibodies (i.due east., immunoglobulins) made from pooled human plasma processed by common cold ethanol fractionation. GamaSTAN is the only IG product licensed in the United States for the prevention of hepatitis A. Only plasma that has tested negative for hepatitis B surface antigen, antibody to human immunodeficiency virus (HIV), and antibody to hepatitis C virus (HCV) is used to produce IG. In improver, the Food and Drug Administration requires that the process used to produce IG include a viral inactivation step or that terminal products test negative for HCV-RNA by polymerase chain reaction. Anti-HAV concentrations differ among IG lots and decreasing concentrations have been observed over the by 30 years, probably because of the decreasing prevalence of previous HAV infection among plasma donors. In 2017, the dosing of GamaSTAN for HAV prevention was increased to reflect this modify in anti-HAV potency.

How does immune globulin (IG) work?

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

When administered for preexposure prophylaxis, a dose of 0.1 mL/kg will provide protection for up to 1 calendar 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 2 months. There is no maximum number of times the bimonthly doses of IG may be repeated as long as hepatitis A prophylaxis is required.

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

How is IG packaged and how is IG administered?

Intramuscular IG is available in single-use vials (ii mL and 10 mL). It should be administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Do not use the gluteal region as an injection site considering of the risk of injury to the sciatic nerve.

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 accept been associated with the formation of blood clots (thrombosis) after administration, particularly if the patient has other take chances factors for thrombosis. Patients should exist counseled virtually this run a risk.

Tin can pregnant 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 old after her mother tested positive for hepatitis A. She's scheduled for her 12-calendar month-erstwhile well-child visit. Volition this impact her vaccination schedule?

Yes. IG may be given whatsoever time before or after inactivated vaccines. However, the antibodies in IG may interfere with the effectiveness of sure alive-virus vaccines, such as measles, mumps, and rubella (MMR) and varicella vaccines. CDC recommends waiting at least half-dozen months from the date of IG administration before administering MMR and varicella vaccines.

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

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

Below is a brief summary of the recommendations:

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

• Infants younger than age 6 months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver disease vaccinated within ii weeks of departure may consider IG in addition to vaccination, based upon the clinician'southward risk assessment • Previously unvaccinated people who are immunocompromised may consider IG in addition to vaccination, regardless of the timing of vaccination, based upon the clinician's adventure cess • Previously unvaccinated people who are over historic period twoscore years and vaccinated within two weeks of departure may consider IG in addition to vaccination, based upon the clinician's risk cess

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

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

Travel - International Back to top

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people age six months or older who are traveling to or working in an area of the world at intermediate or high take chances of hepatitis A manual. Areas of low take a chance include the The states, Canada, Nippon, New Zealand, Australia and Western Europe. Visit the CDC'due south Traveler Health website for more data about specific destinations and current outbreaks or travel notices (https://wwwnc.cdc.gov/travel/). When in doubt, vaccinate.

What are the recommendations for vaccination of travelers to protect them from hepatitis A virus (HAV) infection?

For details on preexposure protection of international travelers historic period 12 months and older, refer to Appendix A on page 35 of the current ACIP recommendations for the prevention of hepatitis A: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Good for you people age 12 months through forty years who are planning travel to an area with loftier or intermediate HAV endemicity and have not received HepA vaccine should receive a unmarried dose of HepA vaccine every bit soon every bit travel is considered and should complete the ii-does series according to the routine schedule.

People with chronic liver disease too every bit adults older than 40 years of historic period, immunocompromised persons, and persons with other chronic medical weather planning to depart to an area with loftier or intermediate HAV endemicity in less than two weeks should receive the initial dose of HepA vaccine and may also simultaneously exist administered IG at a dissever anatomic injection site (for example in dissever limbs).

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2018 to include vaccination of infants 6 through 11 months of age. All infants of this age traveling internationally should be given a dose of measles, mumps, rubella vaccine (MMR) before travel. Due to the potential interference of hepatitis A immune globulin (IG) with MMR vaccine effectiveness, an off-label dose of HepA vaccine is recommended instead of IG in this state of affairs. The travel-related dose for infants six–eleven months of age should not exist counted toward the routine 2-dose series. The routine ii-dose HepA and MMR vaccination series should be initiated at age 12 months according to the routine, historic period-appropriate vaccination schedule.

Infants younger than 6 months and travelers who elect not to receive vaccine or for whom vaccine is contraindicated should receive a unmarried 0.i mL/kg dose of IG before travel when protection confronting HAV is recommended. If travel is for more than ane 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 2 months duration.

Can Twinrix be used for people planning international travel?

Yeah. If time allows, use the standard Twinrix schedule of 3 doses given intramuscularly on a 0, one, and 6 month schedule. If travel is imminent the accelerated 4-dose Twinrix schedule can be used, which is three doses given on days 0, 7, and 21-30 days and a booster dose at 12 months.

Nosotros take an adult patient who received the correct pediatric series of HepA vaccine as a teenager and is now traveling abroad. Does the patient need an adult booster?

No. In that location is no recommendation for a booster dose of HepA if a patient has completed the 2-dose series at any age.

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

Yes. Data have shown that people larn HAV infection even in such places equally 4-star hotels located in Latin America.

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

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

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

Perchance. Since IG protects confronting HAV infection for but i to ii months, depending on the dosage given, boosted IG may be needed if the infant is not yet age half-dozen months. Once the kid has reached half dozen months of age, HepA vaccine should be given.

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

Aye. ACIP recommends that all children age 1 year through 18 years should exist vaccinated against hepatitis A. VFC HepA vaccine may be administered to whatsoever eligible child, including those recommended for vaccination at 6 through eleven months of age as a upshot of travel to an HAV-endemic surface area.

If a person was born and grew upwardly in a country where HAV infection is endemic (e.1000., Vietnam, Mexico) then moved to the United States at historic period 20, 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 amnesty (positive test for total anti-HAV) is the only fashion to decide if vaccination is necessary. For people from countries with high rates of HAV infection, such equally Vietnam and Mexico, serologic testing might be done to preclude unnecessary vaccination. The cost effectiveness of serologic testing, nevertheless, should be balanced against the possibility of delaying needed vaccination while awaiting test results.

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

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

Vaccine Safety Back to top

What reactions might occur after assistants of HepA vaccine?

No serious adverse events accept been attributed definitively to HepA vaccine. Among adults, the near ofttimes reported side effects are soreness at the site of the injection and headache. In children, the nearly ofttimes reported side effect is soreness at the injection site. The frequency of side effects after administration of Twinrix is similar to those reported when the two single-antigen vaccines were administered.

Contraindications and Precautions Back to height

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

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

Can meaning women receive HepA vaccine?

Yes. ACIP recommends that significant women at risk for HAV infection during pregnancy or at risk for a severe outcome from HAV infection should be vaccinated during pregnancy if not previously vaccinated. Pregnant women should be vaccinated for the same indications as non-meaning women. For boosted details, meet page 20 of the current ACIP recommendations: world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Can lactating women receive HepA vaccine?

Yeah. 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 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 any immunocompromised person has a risk factor that places them at increased risk of hepatitis A (e.g., international travel, drug use), they should be vaccinated with HepA vaccine.

I take a patient on interferon for hepatitis C, but I desire to requite 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 exist stored?

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

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

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