Can You Get Hepatitis a More Than Once

Hepatitis A

Affliction Issues Allowed Globulin Vaccine Recommendations Travel - International For Special Groups Vaccine Prophylactic Administering Vaccines Contraindications and Precautions Twinrix Vaccine Storage and Handling

Disease Issues

What is hepatitis A?

Hepatitis A is a liver illness common in many parts of the earth and caused by hepatitis A virus (HAV), a picornavirus that causes acute inflammation of the liver. It 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 exist distinguished from other types of acute viral hepatitis, but it typically has an abrupt onset that can include fever, angst, 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, seventy% of infections are asymptomatic. When illness does occur in immature children, it is typically not accompanied by jaundice. In older children and adults, infection typically is symptomatic, with jaundice occurring in more than 70% of patients.

Hepatitis A signs and symptoms ordinarily resolve in 2-3 months, although ten% to 15% of symptomatic people accept prolonged illness (usually referred to every bit relapsing hepatitis A) lasting upwards to 6 months and should be considered infectious during that time.

How is HAV transmitted?

Person-to-person spread through the fecal-oral road is the primary ways of HAV transmission. Superlative infectivity in infected people occurs during the two week menstruation 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. Transmission currently occurs primarily among susceptible adults.

Mutual-source outbreaks and sporadic cases can occur from exposure to fecally-contaminated food or water. Uncooked HAV-contaminated foods have been recognized as a source of outbreaks. Cooked foods likewise can transmit HAV if the temperature during food preparation is inadequate to impale the virus or if nutrient is contaminated after cooking, as occurs in outbreaks associated with infected food handlers. Transmission of the virus from infected food handlers to nutrient service institution patrons is rare, accounting for 0.2% of the nearly 23,000 outbreak-associated cases of hepatitis A investigated by state wellness departments during 2022-2019.

Until 2017, United states of america incidence rates of hepatitis A were driven by occasional outbreaks, oftentimes linked to viral contamination of imported food. Since 2017, communitywide outbreaks take occurred more frequently, predominantly among people who are continued past specific take chances factors, such as drug apply, and their close contacts.

What is the incubation menstruation for hepatitis A?

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

How is HAV shed?

In infected people, HAV replicates in the liver, is excreted in bile, and is shed in stool. 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 later on jaundice appears, with most people no longer infectious about a calendar week after jaundice appears. Children tin 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 U.s.?

The incidence of hepatitis A in the U.s.a. 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 bodily number of infections: CDC estimates that nigh 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 yr. Beginning in 2022, big 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 then, persistent person-to-person outbreaks have led to substantial increases in hepatitis A infection, with reported cases increasing by over 50% from 2022 to 2019. More information regarding ongoing multistate outbreaks can be constitute here: world wide web.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Practise people die from hepatitis A?

Yes. Decease as a event of fulminant hepatic failure is rare, however, older age (over 40 years) and preexisting chronic liver disease increases the run a risk of severe affliction and death from hepatitis A. The person-to-person U.S. multistate outbreaks that began in 2022 have disproportionately affected adults with chronic liver affliction and other wellness problems related to drug use and unstable housing. From 2022 through Nov 2021, CDC received reports of nearly 43,000 cases of acute HAV infection. Of these, approximately 61% have been hospitalized and 1% (more than than 400 people) take died.

Who is almost at risk for acquiring HAV infection?

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

• Travelers to countries that take high or intermediate endemicity of HAV infection • Men who have sex with men (MSM) • Users of injection and not-injection drugs (in other words, all who use illegal drugs) • People with occupational take a chance of exposure (those who work with HAV-infected non-human primates or researchers handling hepatitis A virus) • People who conceptualize close contact with an international adoptee coming from a country with high or intermediate endemicity of HAV infection • People living with HIV infection • People experiencing homelessness, including temporary shelters and other unstable living arrangements • People living in group settings for those with developmental disabilities and other settings where hygiene is difficult to maintain • People who are incarcerated

I thought people with clotting factor disorders were at chance for hepatitis A due to their regular utilize of blood products. Why did ACIP decide to terminate recommending routine vaccination of people with clotting gene disorders?

People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that time, the process used to make clotting cistron supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased take chances of HAV infection. Mod claret donor screening and virus reduction steps have drastically reduced that run a risk. In addition, more 80% of people with clotting factor disorders at present receive recombinant clotting factor concentrates that are sterilized and take no hazard of HAV manual. As a result of these factors, people with clotting factor 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.

Are people with developmental disabilities at risk of HAV infection?

Historically, HAV infection was highly endemic in institutions for people with developmental disabilities every bit a result of poor manus hygiene, close living weather condition and diaper use. Every bit fewer children accept been institutionalized and as conditions in institutions have improved, the incidence and prevalence of HAV infection have decreased, although outbreaks can occur in these settings. All children with developmental disabilities should receive HepA according to U.Due south. routine vaccine recommendations, including catch up vaccination of all children through age 18 years.

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

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

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

Delight discuss the tests commonly used to diagnose hepatitis A.

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

• Anti-HAV: Total antibiotic to HAV. This diagnostic exam 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. It appears early in the form of infection, remains detectable for the person's lifetime and provides lifelong protection against affliction. Its presence indicates amnesty through either HAV infection or HepA vaccination. • IgM anti-HAV: IgM antibody is a subclass of anti-HAV. Its presence indicates a recent infection with HAV (6 months or less). Information technology is used to diagnose acute (recently acquired) hepatitis A. Because of the risk of false positive IgM anti-HAV results, people should only exist tested for IgM anti-HAV if they are symptomatic and suspected of having acute hepatitis A illness. • HAV RNA tests besides may be used to diagnose acute infection through the direct detection of viral RNA in serum or stool.

Total anti-HAV, which appears early in the class of infection, remains detectable for the person's lifetime and indicates lifelong protection confronting the infection/disease. To confirm a diagnosis of acute HAV infection, serologic testing for IgM anti-HAV is required. In the majority of persons, serum IgM anti-HAV becomes detectable 5 to 10 days earlier onset of symptoms and lasts about 6 months. However, there have been reports of persons who examination positive for IgM anti-HAV for up to a twelvemonth or more than 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/training.htm.

Can HAV be transmitted by blood?

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

Is HAV transmitted by saliva?

In experimentally infected nonhuman primates, HAV has been detected in saliva during the incubation menses; however, manual by homo saliva has not been reported.

How common is HAV manual in infirmary settings?

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

How stable is HAV in the environment?

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

Adequately chlorinating water through h2o handling processes and dilution in public water systems kills HAV. Spas and swimming pools that are adequately treated are non likely to pose a gamble for HAV outbreaks.

Practice people with hepatitis A develop chronic illness or tin they get repeated infections?

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

Vaccination Recommendations Back to top

What is the all-time fashion to prevent HAV infection?

Vaccination with the full series of hepatitis A vaccine (HepA) is the all-time style to prevent HAV infection. Allowed globulin (IG) also can exist used for short-term protection in sure situations.

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

Recommended dosages and schedules of hepatitis A vaccines Vaccine Historic period group Dose Volume # Doses Schedule Havrix (GSK) ane-18 years 720 El.U.* 0.v ml 2 0, half-dozen-12 mos. xix years and older 1440 El.U.* 1.0 ml two 0, six-12 mos. Vaqta (Merck & Co.) one-18 years 25 U** 0.5 ml 2 0, 6-18 mos. nineteen years and older l U** i.0 ml two 0, 6-18 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) ane.0 ml 3 0, i, 6 mos. 4 0, seven, 21-30 days, 12 months***

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

Are HepA vaccine brands interchangeable?

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

Where can I find data most vaccine shortages?

For detailed data about HepA shortages, go to CDC's website at www.cdc.gov/vaccines/hcp/clinical-resources/shortages.html.

Who is recommended to receive HepA vaccine?

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

• All children at age 1 year (12–23 months) • All children and adolescents age ii through 18 years who have not previously received HepA should be vaccinated (i.east., routine take hold of-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 Us, Canada, Western Europe, Nippon, New Zealand, and Australia. For more information, meet the CDC travel health website for current data about specific countries at www.cdc.gov/travel or the CDC Yellow Book (wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-a). When in incertitude, vaccinate. • Infants age 6 through 11 months traveling outside the United States should receive ane dose when protection against HAV infection is recommended. The travel dose does not count toward the routine HepA serial which should be initiated at age 1 yr with the appropriate dose and schedule. In these instances, the child will receive a full 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 close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee's arrival in the U.S. • People who work with HAV-infected nonhuman primates or with HAV in a research laboratory setting • People with chronic liver disease (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 risk factor for exposure or at run a risk for astringent outcome from HAV infection (for example, those with chronic liver disease or with HIV infection). • During an outbreak, whatsoever unvaccinated person who is identified as at risk for HAV infection or at risk for astringent disease from HAV • Whatever person who wishes to be immune to hepatitis A

HepA vaccination is not routinely recommended for healthcare personnel, food handlers, sewage workers, or twenty-four hours intendance providers because there is no evidence that their occupational risks of HAV exposure are significantly college than the general population. However, whatsoever person who desires protection from HAV infection may be vaccinated.

For details about CDC recommendations for the prevention of hepatitis A, see the 2022 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 2022 ACIP statement?

• [added] All children ages 2 through eighteen years not previously vaccinated • [added] All people historic period i twelvemonth or older living with HIV infection • [added] People identified to be at risk for HAV infection during pregnancy • [removed] People with clotting factor disorders

Should we give HepA to a person older than age 18 years who requests it?

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

Which children should be routinely vaccinated confronting HAV infection?

All children should receive 2 doses of HepA vaccine beginning at age 1 twelvemonth (i.eastward., 12–23 months). The 2 doses in the series should be administered at least vi months autonomously. Any kid age 2 through 18 years not 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 betwixt the 2-dose serial is at to the lowest degree 6 months. Is this the same equally 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 iv months after the outset dose. Does it need to be repeated, and if so, when?

Yeah. The second dose was given more than 4 days earlier the minimum interval of 6 calendar months, and then information technology is considered invalid and should be repeated. The echo dose should be administered the proper minimum interval (6 months) after the invalid dose. If this repeat dose is inadvertently given less than six months later on the invalid dose, it does non demand to be repeated once more every bit long every bit the interval betwixt the initial HepA vaccine and the most recent dose is at least six 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). Delight see the consummate PEP recommendations at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, with special attending to Table iv on folio xix and Appendix B: Provider Guidance on Chance Assessment for Hepatitis A Postexposure Prophylaxis, beginning on page 36.

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

People age 12 months and older exposed to HAV within the past xiv days and who have non previously completed the HepA vaccine series should receive a single dose of HepA vaccine as before long as possible. In addition to vaccine, allowed globulin (IG; 0.1 mL/kg) may be administered to people older than age 40 years depending on the providers' risk cess. For long-term immunity, the HepA vaccine series should exist completed with a second dose at least vi months subsequently the first dose. Notwithstanding, the second dose is not necessary for PEP. A second dose should not be administered sooner than six calendar months after the first dose, regardless of HAV exposure gamble.

People age 12 months or older who are immunocompromised or have chronic liver disease, and who accept been exposed to HAV within the by 14 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) every bit soon as possible after exposure. For long-term immunity, the HepA vaccination series should be completed with a 2nd dose at least six months after the first dose. Still, the second dose is not necessary for PEP. A 2d dose should not be administered sooner than 6 calendar months later on the first dose, regardless of HAV exposure chance.

People with HIV infection develop protective levels of antibody more slowly and are less likely to develop protective antibody levels after vaccination with HepA, particularly if their CD4+ count is 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 not fully vaccinated; however, CDC too advises clinicians to consider administering IG PEP to an individual with HIV after a high-chance exposure (such as a household or sexual contact) even if the private has been fully vaccinated.

Twinrix contains half the amount of hepatitis A antigen every bit a standard single-dose adult HepA vaccine. Twinrix should not be used for PEP but may exist used to confer protection to at-risk simply not still 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 every bit soon equally possible and within 2 weeks of exposure. MMR and varicella vaccines should not be administered sooner than 6 months after IG administration in order to avoid possible IG interference with the effectiveness of MMR and varicella vaccines.

When should prevaccination anti-HAV testing for susceptibility be performed?

Prevaccination serologic testing for HAV (measuring either total anti-HAV or IgG anti-HAV) is not indicated for children because of the low prevalence of infection in children. It too is non 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 be used if it poses a barrier to vaccinating susceptible people, especially people who are hard to access.

Prevaccination testing is most likely to be toll-effective for adults who were either built-in in or lived for long periods of time in areas of the world with high or intermediate hepatitis A endemicity. When evaluating people from populations with high rates of previous HAV infection, vaccination history also should be obtained, if feasible. If testing or vaccination history is not bachelor, do not postpone vaccinating. There is no harm in vaccinating a person who has had natural infection or previous doses of vaccine.

When should postvaccination testing be performed?

Serologic testing for immunity is non necessary after routine vaccination of infants, children or adults. Testing for the presence of anti-HAV antibody one month or more afterwards completing the HepA vaccination series is recommended only for people whose futurity clinical management depends on knowing their allowed status and for whom revaccination might be indicated, such as people living with HIV and other immunocompromised persons (such as transplant recipients and people vaccinated while receiving chemotherapy). In such individuals, if the results of postvaccination testing do not show an adequate immune response (ten mIU/mL or college), revaccination with a complete series is recommended, followed by a 2nd postvaccination serologic test. If that 2d exam remains negative, no additional vaccination is recommended; however, the patient should exist counseled on strategies to avoid exposure to HAV and the demand for IG if an exposure occurs. If vaccination results in seroconversion, bereft information are available to brand recommendations concerning repeat testing, booster doses or revaccination.

For Special Groups Dorsum to tiptop

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

ACIP recommends vaccination confronting HAV infection for all previously unvaccinated people who anticipate having close personal contact with an international adoptee from a land of loftier or intermediate endemicity during the outset sixty days following the adoptee's arrival in the U.South. In improver to the adoptee's new parents and siblings, this grouping might include grandparents, other household members, regular babysitters and other caregivers. The first dose of HepA should be given to close contacts every bit shortly as adoption is planned, ideally at least two weeks before the arrival of the adoptee. A 2d dose should be given no sooner than 6 months afterward the first dose.

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

The 2022 ACIP recommendations for the prevention of hepatitis A define a person experiencing homelessness equally 1) a person who lacks housing (regardless of whether the person is a fellow member of a family), including a person whose chief residence during the night is a supervised public or private facility (east.g., shelter) that provides temporary living accommodations and a person who is a resident in transitional housing, two) a person without permanent housing who might: alive on the streets, stay in a shelter, mission, single-room occupancy facility, abandoned building, vehicle, or whatsoever 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 members. In add-on, previously homeless persons who are to be released from a prison or a infirmary might be considered homeless if they do not have a stable housing state of affairs to which they tin can return. The instability of a person'south living arrangements is disquisitional to the definition of homelessness.

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

While a consummate 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 prevent or command outbreaks of hepatitis A. People who are experiencing homelessness may have difficulty protecting themselves from exposure to HAV in other ways considering of their living conditions. They should be vaccinated when possible and provided a record of immunization. Reporting the HepA vaccination to a land immunization information system besides 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 considering of their occupation. However, if HCPs are going to work (or vacation) in a land with a high or intermediate endemic charge per unit of HAV infection, they are at take chances of HAV infection and should be vaccinated. The only occupational indications for routine HepA vaccination are work with not-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 among children in kid care centers, infecting employees of those centers, especially those caring for infants and toddlers. Post-obit widespread adoption of early childhood vaccination against hepatitis A, outbreaks in child intendance centers are now rare.

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

Although not at increased take a chance for HAV infection, people with chronic liver illness are at increased adventure for fulminant hepatitis A, hospitalization and death if they get 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 matter disposal workers?

In published reports of three serologic surveys conducted amidst The states wastewater workers and advisable comparison 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 United States. In addition, in the United states of america, outbreaks of hepatitis A caused by flooding, which can carry raw sewage, accept not been reported.

Why is hepatitis A vaccination no longer recommended for 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 procedure 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 gamble. In addition, more than 80% of people with clotting factor disorders now receive recombinant clotting gene concentrates that are sterilized and take no risk of HAV manual. Equally a result of these factors, people with clotting factor disorders now have no greater take chances of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless information technology is otherwise indicated.

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

Because of measles. Measles is highly communicable and poses a serious threat to the health of unvaccinated infants. For this reason, all infants historic period half dozen through eleven months who travel internationally are recommended to receive a dose of measles, mumps, and rubella vaccine (MMR) to reduce the gamble of measles infection during travel.

The antibodies in immune globulin (IG) typically used to forbid HAV infection in infants before the first birthday can interfere with the effectiveness of MMR vaccine. An infant who is given IG should not be vaccinated with MMR or varicella vaccines for at to the lowest degree half-dozen months subsequently IG administration. If an infant age 6 through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-characterization use of HepA vaccine (not IG) in improver to MMR. The HepA and MMR doses administered earlier the first birthday do not count toward the routine vaccination series of either vaccine: these infant travelers will still need ii doses of HepA and two doses of MMR when age advisable.

Can pregnant women receive hepatitis A vaccine?

Yes. The ACIP recommends that pregnant women at risk for HAV infection during pregnancy or at risk for a severe consequence from HAV infection should be vaccinated during pregnancy if not previously vaccinated. Meaning women should be vaccinated for the aforementioned 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 top

By what method should hepatitis A vaccine be administered?

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

Tin HepA vaccine exist given meantime with other vaccines?

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

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

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

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

You do not need to start the series over once more. The immunogenicity of 1 dose of HepA vaccine is 94% to 100%; studies have shown persistent protection from a unmarried dose lasting more than 10 years. To ensure optimal long-term protection it is important to administrate the 2d dose.

To consummate a 21-yr-former patient'due south HepA vaccine serial, how many adult doses should I give if the patient received a single dose of pediatric HepA vaccine 5 years ago?

A person should receive the dosage of HepA vaccine appropriate for their age at the time of administration. You should give the patient ane developed dose of HepA to complete the 2-dose series. It is not necessary to restart the vaccine serial.

I of our staff gave a dose of pediatric HepA vaccine to an developed patient past mistake. How do we remedy this error?

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

If yous give more an age-appropriate dose (for example, an adult dose of HepA vaccine given to a kid), count the dose every bit valid and notify the patient/parent about the error. There may be an increased risk of a local adverse reaction when more than the recommended dose is given. If the fault occurred with the offset dose of the serial the kid should nonetheless receive the 2d dose on schedule. Giving a "double" dose for the beginning dose does not negate the need for a 2nd dose.

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

Why does a 15 year former who weighs 160 pounds receive a pediatric dose of HepA while his 110-pound mother receives an developed 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 age-based efficacy data. The same holds true for HepB vaccine. In addition, higher response rates are expected in younger people, fifty-fifty if their weights are above the norm.

Could you please provide more than information almost 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 20 mcg of hepatitis B antigen (the total Engerix-B adult dose).

In the U.S., Twinrix is licensed for utilise in people who are age 18 years or older. Information technology can be administered to people who are at take chances for both hepatitis A and hepatitis B, such as certain international travelers, people with HIV infection, people with chronic liver disease not acquired past hepatitis B, men who accept 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 six month schedule. In 2007, the FDA also approved a 4-dose schedule for Twinrix. Information technology consists of iii doses given within 4 weeks, followed by a booster dose at 12 months (0, 7 days, 21–30 days, and 12 months). The 4-dose schedule could benefit individuals needing rapid protection from hepatitis A and hepatitis B, such as people traveling to high-prevalence areas imminently.

Twinrix cannot be used for postexposure prophylaxis.

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

Twinrix is licensed as a 3-dose series for people historic period eighteen years and older. If Twinrix is not available or if you lot choose non to use Twinrix to complete the Twinrix series, you should do the following: If 1 dose of Twinrix was given, consummate the series with 2 adult doses of hepatitis B vaccine and 2 developed 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 developed 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 can be substituted for any dose of the hepatitis B series but non for whatever dose of the hepatitis A series.

• Whatsoever combination of 3 doses of developed hepatitis B or 3 doses of Twinrix is a complete series of hepatitis B vaccine. • One dose of Twinrix + ii doses of adult hepatitis A is a complete series of hepatitis A vaccine. • Two doses of Twinrix + 1 dose of adult hepatitis A is a consummate series of hepatitis A vaccine.

We're thinking of using Twinrix and we're wondering whether we can utilize it for doses #one and #iii only and use single antigen hepatitis B vaccine for dose #ii?

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

Immune Globulin Back to top

What is immune globulin (IG)?

Immune globulin (IG, GamaSTAN, Grifols Therapeutics) is a sterile preparation of full-bodied antibodies (i.east., immunoglobulins) made from pooled human plasma processed by common cold ethanol fractionation. GamaSTAN is the just IG product licensed in the United states for the prevention of hepatitis A. But plasma that has tested negative for hepatitis B surface antigen, antibody to human immunodeficiency virus (HIV), and antibiotic to hepatitis C virus (HCV) is used to produce IG. In add-on, the Food and Drug Administration requires that the process used to produce IG include a viral inactivation step or that final products examination negative for HCV-RNA past polymerase chain reaction. Anti-HAV concentrations differ among IG lots and decreasing concentrations take been observed over the past thirty years, probably because of the decreasing prevalence of previous HAV infection among plasma donors. In 2017, the dosing of GamaSTAN for HAV prevention was increased to reflect this change in anti-HAV say-so.

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 i to ii months.

When administered for preexposure prophylaxis, a dose of 0.i mL/kg will provide protection for upwards to 1 calendar month and a dose of 0.2 mL/kg will provide protection for up to ii 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 equally 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 (two mL and x mL). It should be administered intramuscularly, preferably in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. Do not use the gluteal region as an injection site because of the gamble of injury to the sciatic nerve.

Does IG cause agin events?

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

Can pregnant or lactating women receive IG?

Yes. Pregnancy or lactation is not 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 later on her mother tested positive for hepatitis A. She's scheduled for her 12-month-former well-child visit. Will this affect her vaccination schedule?

Yes. IG may exist given any fourth dimension before or afterward inactivated vaccines. However, the antibodies in IG may interfere with the effectiveness of certain live-virus vaccines, such equally measles, mumps, and rubella (MMR) and varicella vaccines. CDC recommends waiting at least half-dozen months from the date of IG assistants before administering MMR and varicella vaccines.

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

Please see details of the recommendations for the employ of IG for the prevention of hepatitis A provided in Table iv (page 19) and Appendices A and B of the 2022 ACIP recommendations for the prevention of hepatitis A infection: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Beneath is a cursory summary of the recommendations:

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

• Infants younger than historic period 6 months and other travelers for whom HepA vaccine is declined or contraindicated • Previously unvaccinated people with chronic liver disease vaccinated within ii weeks of departure may consider IG in addition to vaccination, based upon the clinician's risk assessment • Previously unvaccinated people who are immunocompromised may consider IG in addition to vaccination, regardless of the timing of vaccination, based upon the clinician's risk cess • Previously unvaccinated people who are over historic period 40 years and vaccinated within two weeks of divergence may consider IG in addition to vaccination, based upon the clinician's adventure assessment

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

• Infants nether 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 age 40 years, consider IG in addition to vaccination, based upon clinician adventure assessment • People with HIV infection, previously vaccinated, consider IG following a high-risk exposure (household or sexual contact), based upon clinician take chances assessment

Travel - International Back to top

Which travelers are recommended to receive HepA vaccine?

Hepatitis A vaccination is recommended for people historic period vi months or older who are traveling to or working in an area of the world at intermediate or high risk of hepatitis A transmission. Areas of low risk include the United States, Canada, Japan, New Zealand, Australia and Western Europe. Visit the CDC'south Traveler Health website for more information virtually specific destinations and current outbreaks or travel notices (https://wwwnc.cdc.gov/travel/). When in uncertainty, 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: world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Healthy people age 12 months through 40 years who are planning travel to an area with high or intermediate HAV endemicity and have not received HepA vaccine should receive a unmarried dose of HepA vaccine as soon every bit travel is considered and should complete the ii-does serial according to the routine schedule.

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

ACIP revised its recommendations for preexposure hepatitis A vaccination for travelers in 2022 to include vaccination of infants 6 through xi months of age. All infants of this age traveling internationally should exist given a dose of measles, mumps, rubella vaccine (MMR) before travel. Due to the potential interference of hepatitis A immune globulin (IG) with MMR vaccine effectiveness, an off-label dose of HepA vaccine is recommended instead of IG in this situation. The travel-related dose for infants half-dozen–11 months of age should non be counted toward the routine 2-dose series. The routine two-dose HepA and MMR vaccination series should exist initiated at age 12 months according to the routine, age-advisable vaccination schedule.

Infants younger than six months and travelers who elect not to receive vaccine or for whom vaccine is contraindicated should receive a single 0.1 mL/kg dose of IG before travel when protection against HAV is recommended. If travel is for more than 1 month, a dose of 0.2 mL/kg should be administered. A 0.2 mL/kg dose can exist repeated every 2 months for travel of more than 2 months elapsing.

Can Twinrix be used for people planning international travel?

Aye. If fourth dimension allows, use the standard Twinrix schedule of 3 doses given intramuscularly on a 0, 1, and half dozen calendar month schedule. If travel is imminent the accelerated four-dose Twinrix schedule tin be used, which is iii doses given on days 0, 7, and 21-xxx days and a booster dose at 12 months.

We accept an adult patient who received the correct pediatric serial of HepA vaccine as a teenager and is at present traveling abroad. Does the patient need an adult booster?

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

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

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

If a traveler received the first dose of HepA vaccine more than i year agone and needs to travel abroad imminently, will the traveler demand IG in addition to dose #2 prior to leaving?

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

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

Mayhap. Since IG protects against HAV infection for only 1 to ii months, depending on the dosage given, additional IG may be needed if the infant is non however age 6 months. Once 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 1 year through 18 years should exist vaccinated against hepatitis A. VFC HepA vaccine may exist administered to whatsoever eligible child, including those recommended for vaccination at vi through 11 months of age as a result of travel to an HAV-endemic area.

If a person was born and grew upwardly in a country where HAV infection is owned (due east.m., Vietnam, Mexico) and then moved to the United States at age 20, should that person receive HepA vaccine earlier returning to visit his/her homeland?

It depends on whether that person has a history of HAV infection. Unless there are medical records that certificate prior HAV infection, serologic testing for immunity (positive test for total anti-HAV) is the only fashion to determine if vaccination is necessary. For people from countries with loftier rates of HAV infection, such equally Vietnam and Mexico, serologic testing might exist done to prevent unnecessary vaccination. The cost effectiveness of serologic testing, still, 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 every bit in that location are medical records that document that the person was previously infected with HAV (i.e., positive test for total anti-HAV). If there is any doubt that the person really was infected with HAV, HepA vaccine and/or IG should exist given. The vaccine or IG will not harm a person who is already immune.

Vaccine 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 virtually oft reported side furnishings are soreness at the site of the injection and headache. In children, the virtually oftentimes reported side issue 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 top

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

Hepatitis A vaccine is contraindicated for people with a history of a severe allergic reaction to a previous dose of HepA vaccine or to a vaccine component. As with all other vaccines, 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 pregnant women at gamble for HAV infection during pregnancy or at risk for a astringent issue from HAV infection should be vaccinated during pregnancy if non previously vaccinated. Pregnant women should be vaccinated for the same indications as non-pregnant women. For additional details, come across folio 20 of the current ACIP recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.

Tin lactating women receive HepA vaccine?

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

Can HepA vaccine be given to immunocompromised people?

Aye. All people age 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 take chances factor that places them at increased risk of hepatitis A (e.g., international travel, drug use), they should exist vaccinated with HepA vaccine.

I take a patient on interferon for hepatitis C, but I want 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 Treatment

How should HepA vaccine be stored?

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

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

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