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Lesson 10. Hepatitis A

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References

  • Advisory Committee on Immunization Practices (ACIP), Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55:1-23.
  • Advisory Committee on Immunization Practices. Supplementary text 1. Provider Guidance on Risk Assessment and Clinical Decision-making for Hepatitis A Postexposure Prophylaxis. Supplements: Update: Recommendations of the Advisory Committee on Immunization Practices for use of Hepatitis A vaccine for post-exposure prophylaxis and for international travel. November 2, 2018
    [CDC] -
  • Bell BP, Shapiro CN, Alter MJ, et al. The diverse patterns of hepatitis A epidemiology in the United States-implications for vaccination strategies. J Infect Dis. 1998;178:1579-84.
  • Bialek SR, Barry V, Bell BP, et al. Seroprevalence and correlates of hepatitis a among HIV-negative American men who have sex with men. Sex Health. 2011;8:343-8.
  • Bohm SR, Berger KW, Hackert PB, et al. Hepatitis A outbreak among adults with developmental disabilities in group homes--Michigan, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:148-52.
  • Bower WA, Nainan OV, Han X, Margolis HS. Duration of viremia in hepatitis A virus infection. J Infect Dis. 2000;182:12-7.
  • Brennan J, Moore K, Sizemore L, et al. Notes from the Field: Acute Hepatitis A Virus Infection Among Previously Vaccinated Persons with HIV Infection - Tennessee, 2018. MMWR Morb Mortal Wkly Rep. 2019;68:328-329.
  • Brundage SC, Fitzpatrick AN. Hepatitis A. Am Fam Physician. 2006;73:2162-8.
  • Centers for Disease Control and Prevention (CDC). Hepatitis A Surveillance 2022. April 2024.
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  • Cuthbert JA. Hepatitis A: old and new. Clin Microbiol Rev. 2001;14:38-58.
  • Doshani M, Weng M, Moore KL, Romero JR, Nelson NP. Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness. MMWR Morb Mortal Wkly Rep. 2019;68:153-156.
  • Foster M, Ramachandran S, Myatt K, et al. Hepatitis A Virus Outbreaks Associated with Drug Use and Homelessness - California, Kentucky, Michigan, and Utah, 2017. MMWR Morb Mortal Wkly Rep. 2018;67:1208-1210.
  • Foster MA, Hofmeister MG, Kupronis BA, et al. Increase in Hepatitis A Virus Infections - United States, 2013-2018. MMWR Morb Mortal Wkly Rep. 2019;68:413-5.
  • Girardi E, Scognamiglio P, Sciarrone MR, et al. High HIV prevalence in male patients with acute hepatitis A in the Rome metropolitan area, Italy 2002-2008. J Hepatol. 2011;54:1102-6.
  • Klevens RM, Kruszon-Moran D, Wasley A, et al. Seroprevalence of hepatitis A virus antibodies in the U.S.: results from the National Health and Nutrition Examination Survey. Public Health Rep. 2011;126:522-32.
  • Latash J, Dorsinville M, Del Rosso P, et al. Notes from the Field: Increase in Reported Hepatitis A Infections Among Men Who Have Sex with Men - New York City, January-August 2017. MMWR Morb Mortal Wkly Rep. 2017;66:999-1000.
  • Link-Gelles R, Hofmeister MG, Nelson NP. Use of hepatitis A vaccine for post-exposure prophylaxis in individuals over 40 years of age: A systematic review of published studies and recommendations for vaccine use. Vaccine. 2018;36:2745-50.
  • Litt IF, Cohen MI. Perihepatitis associated with salpingitis in adolescents. JAMA. 1978;240:1253-4.
  • Lu PJ, Byrd KK, Murphy TV. Hepatitis A vaccination coverage among adults 18-49 years traveling to a country of high or intermediate endemicity, United States. Vaccine. 2013;31:2348-57.
  • Ly KN, Klevens RM. Trends in disease and complications of hepatitis A virus infection in the United States, 1999-2011: a new concern for adults. J Infect Dis. 2015;212:176-82.
  • McKnight KL, Lemon SM. Hepatitis A Virus Genome Organization and Replication Strategy. Cold Spring Harb Perspect Med. 2018;8(12). pii: a033480.
  • Nainan OV, Xia G, Vaughan G, Margolis HS. Diagnosis of hepatitis a virus infection: a molecular approach. Clin Microbiol Rev. 2006;19:63-79.
  • Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel. MMWR Morb Mortal Wkly Rep. 2018;67:1216-1220.
  • Nelson NP, Weng MK, Hofmeister MG, et al. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep. 2020;69:1-38.
  • Nelson NP. Updated Dosing Instructions for Immune Globulin (Human) GamaSTAN S/D for Hepatitis A Virus Prophylaxis. MMWR Morb Mortal Wkly Rep. 2017;66:959-960.
  • Ott JJ, Irving G, Wiersma ST. Long-term protective effects of hepatitis A vaccines. A systematic review. Vaccine. 2012;31:3-11.
  • Raczniak GA, Bulkow LR, Bruce MG, et al. Long-term immunogenicity of hepatitis A virus vaccine in Alaska 17 years after initial childhood series. J Infect Dis. 2013;207:493-6.
  • Raczniak GA, Thomas TK, Bulkow LR, et al. Duration of protection against hepatitis A for the current two-dose vaccine compared to a three-dose vaccine schedule in children. Vaccine. 2013;31:2152-5.
  • Regan DG, Wood JG, Benevent C, et al. Estimating the critical immunity threshold for preventing hepatitis A outbreaks in men who have sex with men. Epidemiol Infect. 2016;144:1528-37.
  • Sharapov UM, Bulkow LR, Negus SE, et al. Persistence of hepatitis A vaccine induced seropositivity in infants and young children by maternal antibody status: 10-year follow-up. Hepatology. 2012;56:516-22.
  • Storch GA, Bodicky C, Parker M, Blecka LJ, Aach RD. Use of conventional and IgM-specific radioimmunoassays for anti-hepatitis A antibody in an outbreak of hepatitis A. Am J Med. 1982;73:663-8.
  • Tong MJ, el-Farra NS, Grew MI. Clinical manifestations of hepatitis A: recent experience in a community teaching hospital. J Infect Dis. 1995;171 Suppl 1:S15-8.
  • Van Herck K, Jacquet JM, Van Damme P. Antibody persistence and immune memory in healthy adults following vaccination with a two-dose inactivated hepatitis A vaccine: long-term follow-up at 15 years. J Med Virol. 2011;83:1885-91.
  • Victor JC, Monto AS, Surdina TY, et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med. 2007;357:1685-94.
  • Wallace MR, Brandt CJ, Earhart KC, et al. Safety and immunogenicity of an inactivated hepatitis A vaccine among HIV-infected subjects. Clin Infect Dis. 2004;39:1207-13.
  • Winokur PL, Stapleton JT. Immunoglobulin prophylaxis for hepatitis A. Clin Infect Dis. 1992;14:580-6.
  • Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. Viral hepatitis infections: hepatitis A virus (HAV) infection. MMWR Recomm Rep. 2021;70(No. RR-4):1-187.

Tables

Table 1.

Recommended Regimens: Dose and Schedule for Hepatitis A Vaccines
Vaccine Age Group Dosage Route Schedule Booster
Havrix 1-18 years
≥19 years		 0.5 mL (720 ELU)
1.0 mL (1,440 ELU)		 IM
IM		 0, 6-12 months
0, 6-12 months		 None
None
Vaqta 1-18 years
≥19 years		 0.5 mL (25 U)
1 ml (50 U)		 IM
IM		 0, 6-18 months
0, 6-18 months		 None
None
Twinrix ≥18 years (primary)
≥18 years (accelerated)		 1 mL (720 ELU HAV + 20 µg HBsAg)
1 mL (720 ELU HAV + 20 µg HBsAg)		 IM
IM		 0, 1, 6 months
0, 7, 21-30 days		 None
12 months
Abbreviations: ELU = ELISA units of inactivated HAV: HBV= hepatitis B Virus; HbsAg = hepatitis B surface antigen
Source:
  • Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel. MMWR Morb Mortal Wkly Rep. 2018;67:1216-1220. [PubMed Abstract]
Table 2.

Recommendations for Postexposure Prophylaxis Following Exposure to Hepatitis A Virus (HAV)
Indication/Age Group Risk Category/Health Status HAV Vaccine Immune Globulin
<1 year Healthy No 0.1 mL/kg body weight*
1-40 years Healthy 1 dose^ None
>40 years Healthy 1 dose^ 0.1 mL/kg body weight§
≥1 Year Immunocompromised or chronic liver Disease 1 dose^ 0.1 mL/kg body weight#
≥1 Year Vaccine Contraindication** No 0.1 mL/kg body weight*

*Measles, mumps, and rubella vaccine should not be administered for at least 3 months after receipt of Immune globulin
^A second dose is not required for postexposure prophylaxis; however, for long-term immunity, the hepatitis A vaccination series should be completed with a second dose at least 6 months after the first dose.
§The provider’s risk assessment should determine the need for immune globulin administration. If the provider’s risk assessment determines that both vaccine and immune globulin are warranted, HepA vaccine and immune globulin should be administered simultaneously at different anatomic sites.
#Vaccine and immune globulin should be administered simultaneously at different anatomic sites.
**Life-threatening allergic reaction to a previous dose of hepatitis A vaccine, or allergy to any vaccine component.
Source:
  • Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel. MMWR Morb Mortal Wkly Rep. 2018;67:1216-1220. [PubMed Abstract]

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