Hepatitis A and Hepatitis A Vaccine

Epidemiology and Prevention of VaccinePreventable Diseases

National Immunization Program Centers for Disease Control and Prevention

Revised March 2002

Hepatitis A
Epidemic jaundice described by Hippocrates Differentiated from hepatitis B in 1940s Serologic tests developed in 1970s Most commonly reported type of hepatitis in the United States

Hepatitis A Virus
Picornavirus (RNA) Humans are only natural host

Stable at low pH
Inactivated by high temperature, formalin, chlorine

Hepatitis A Pathogenesis
Entry into mouth Viral replication in the liver

Virus present in blood and feces 1012 days after infection

Virus excretion may continue for up to 3 weeks after onset of symptoms

Hepatitis A Clinical Features

Incubation period 28 days (range 1550 days) Illness not specific for hepatitis A Likelihood of symptomatic illness directly related to age

Children generally asymptomatic, adults symptomatic

Hepatitis A Epidemiology
Reservoir Transmission Human. Endemic Fecal-oral

Temporal pattern
Communicability

None
2 weeks before to 1 week after onset

Source of Hepatitis A Infection

Day care 15% Intl travel 5% Outbreak 3% Household/ sexual 25%

Unknown 52%

Hepatitis A United States, 1966-2001*

70000 60000 50000

Vaccine Licensed

Cases

40000 30000 20000 10000 0 1966 1970 1974 1978 1982 1986 1990 1994 1998

*2001 provisional data

Hepatitis A Incidence* by Age Group

20 18 16 14 12 10 8 6 4 2 0

Rate

<5

5-14

15-24

25-39

40+

Age group (yrs)

*rate per 100,000 population. 1997 data.

Hepatitis A Incidence - United States and American Indians, 1990-2000

U.S. American Indians
Vaccine Licensed

120 100 80
Rate
American Indians ACIP Recommendation

60 40 20 0 1990
United States

1992

1994

1996

1998

2000

Source: National Notifiable Diseases Surveillance System, CDC

Hepatitis A Vaccines
Inactivated whole virus HAVRIX (GlaxoSmithKline) VAQTA (Merck Vaccine Division) Pediatric and adult formulations Licensed for persons >2 years

Hepatitis A Vaccines
Formulation HAVRIX VAQTA Pediatric age 2-18 yrs 2-18 yrs dose 0.5 ml 0.5 ml Adult age >18 yrs >18 yrs dose 1.0 ml 1.0 ml

Hepatitis A Vaccine Immunogenicity

Adults 95% seropositive after one dose 100% seropositive after two doses
Children (>2 years) and Adolescents >97% seropositive after one 100% seropositive after 2 doses

Hepatitis A Vaccine Efficacy

GlaxoSmithKline 40,000 Thai children 4-15 years Vaccine efficacy 94% Merck 1,000 children 2-16 years Vaccine efficacy 100%

Hepatitis A Vaccines
Adult 1 dose Booster dose 6 - 18 months after first dose Children and Adolescent 1 dose Booster dose 6 - 18 months after first dose

Hepatitis A Vaccine Recommendations

Routine hepatitis A vaccination is recommended for: Children >2 years in states, counties, or communities where the average annual hepatitis A rate during 19871997 was >20 per 100,000 population

Hepatitis A Vaccination Strategies High Incidence States

One or more single age cohorts of children or adolescents Children in settings such as day care Children and adolescents in a wide range of ages in a variety of settings, such as when they seek health care for other purposes

Hepatitis A Vaccine Recommendations

Routine hepatitis A vaccination should be considered for: Children >2 years in states, counties, or communities where the average annual hepatitis A rate during 19871997 was 10 to 20 per 100,000 population

Hepatitis A Vaccination Strategies Intermediate Incidence States

Statewide or community-based? Clustering of high-incidence areas within the state Feasibility

Impact on incidence

Hepatitis A High Incidence States

>20/100,000 population 10-20/100,000 population

Twinrix
Combination hepatitis B (adult dose) and hepatitis A vaccine (pediatric dose)

Schedule: 0, 1, 6-12 months Approved for persons >18 years

Hepatitis A Vaccine Recommendations International travelers Men who have sex with men Drug users Persons with occupational risk Persons with chronic liver disease, including hepatitis C

Hepatitis A Vaccine Recommendations Travelers to high or intermediate risk countries Protected by 4 weeks after dose Give concurrent IG for travel in <4 weeks

Hepatitis A Vaccine Recommendations Health care workers: not routinely recommended Day care centers: not routinely recommended Food handlers: may be considered based on local circumstances

Hepatitis A Serologic Testing

Prevaccination Not indicated for children May be considered for some adults and older adolescents Postvaccination Not indicated

Hepatitis A Vaccine Adverse Reactions

Pain at injection site Systemic reactions uncommon

No serious adverse events reported

Hepatitis A Vaccine Contraindications and Precautions Severe allergy to vaccine component or following prior dose Moderate or severe acute illness

National Immunization Program

Hotline Email Website 800.232.2522 nipinfo@cdc.gov www.cdc.gov/nip