Hepatitis A and

Hepatitis A Vaccine

Epidemiology and Prevention of Vaccine-

Preventable 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 10-12

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 15-
50 days)

• Illness not specific for hepatitis A

• Likelihood of symptomatic illness
directly related to age

• Children generally asymptomatic,

adults symptomatic
 Hepatitis A Epidemiology
• Reservoir Human. Endemic

• Transmission Fecal-oral

• Temporal pattern None

• Communicability 2 weeks before to 1

week after onset
Source of Hepatitis A Infection
Household/
Day care
sexual
15%
25%

Intl travel
5%
Outbreak
3%

Unknown
52%
Hepatitis A – United States, 1966-2001*

70000
60000 Vaccine
50000 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
Rate

10
8
6
4
2
0
<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 American Indians ACIP Recommendation

80
Rate

60
40
20 United States
0
1990 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 1987-
1997 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 1987-
1997 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 800.232.2522

• Email nipinfo@cdc.gov

• Website www.cdc.gov/nip