Hepatitis A/Secondary Prevention

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Overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Until recently, an injection of immune globulin (IG) was the only recommended way to protect people after they have been exposed to hepatitis A virus. In June 2007, U.S. guidelines were revised to allow for hepatitis A vaccine to be used after exposure to prevent infection in healthy persons aged 1–40 years. Persons who recently have been exposed to hepatitis A virus (HAV) and who previously have not received hepatitis A vaccine should be administered a single dose of single-antigen vaccine or immunoglobulin (IG) (0.02 mL/kg) as soon as possible. Information about the relative efficacy of vaccine compared with immunoglobulin postexposure is limited, and no data are available for persons aged more than 40 years or those with underlying medical conditions. Therefore, decisions to use vaccine or immunoglobulin should take into account patient characteristics associated with more severe manifestations of hepatitis A, including older age and chronic liver disease.

Secondary Prevention

Choices for Secondary Prevention

Secondary prevention for hepatitis A can be achieved either by vaccination or by the administration of immune globulins. Decisions to use vaccine or immunoglobulin should take into account patient characteristics associated with more severe manifestations of hepatitis A, including older age and chronic liver disease. The magnitude of the risk for HAV transmission from the exposure should be considered in decisions to use immunoglobulin or vaccine.

• Persons who recently have been exposed to HAV and who previously have not received hepatitis A vaccine should be administered a single dose of single-antigen vaccine or immunoglobulin (IG) (0.02 mL/kg) as soon as possible.
• For healthy persons aged 12 months to 40 years, single-antigen hepatitis A vaccine at the age-appropriate dose is preferred over immunoglobulin because of vaccine advantages, including long-term protection and ease of administration.
• For persons aged more than 40 years, immunoglobulin is preferred because of the absence of information regarding vaccine performance and the more severe manifestations of hepatitis A in this age group; vaccine can be used if immunoglobulin cannot be obtained.
• Immunoglobulin should be used for children aged less than 12 months, immunocompromised persons, persons who have had diagnosed CLD, and persons for whom vaccine is contraindicated.
• If immunoglobulin is administered to persons for whom hepatitis A vaccine also is recommended, a dose of vaccine should be provided simultaneously with immunoglobulin. The second vaccine dose should be administered according to the licensed schedule to complete the series. The efficacy of immunoglobulin or vaccine when administered greater than 2 weeks after exposure has not been established.

Indications for Postexposure Prophylaxis

Close Personal Contacts

• Close personal contacts with serologically confirmed hepatitis A include:
  • Household and sex contacts
  • Persons who have shared illicit drugs with someone with hepatitis A
• Consideration should also be given to providing IG or hepatitis A vaccine to persons with other types of ongoing, close personal contact with a person with hepatitis A (e.g., a regular babysitter or caretaker).

Child-care Center Staff, Attendees, and Attendees' Household Members

• Post-exposure prophylaxis should be administered to all previously unvaccinated staff and attendees of child care centers or homes if 1) one or more cases of hepatitis A are recognized in children or employees or 2) cases are recognized in two or more households of center attendees.
• In centers that provide care only to older children who no longer wear diapers, post-exposure prophylaxis need be administered only to classroom contacts of the index patient (i.e., not to children or staff in other classrooms).
• When an outbreak occurs (i.e., hepatitis A cases in three or more families), post-exposure prophylaxis should also be considered for members of households that have diaper-wearing children attending the center.

Persons Exposed to a Common Source, Such as an Infected Food Handler

• If a food handler receives a diagnosis of hepatitis A, post-exposure prophylaxis should be administered to other food handlers at the same establishment. Because transmission to patrons is unlikely, post-exposure prophylaxis administration to patrons typically is not indicated but may be considered if:
  • During the time when the food handler was likely to be infectious, the food handler both directly handled uncooked foods or foods after cooking and had diarrhea or poor hygienic practices.
  • Patrons can be identified and treated within 2 weeks of exposure.
• In settings in which repeated exposures to HAV might have occurred, such as institutional cafeterias, stronger consideration of post-exposure prophylaxis use might be warranted.

Case of hepatitis A is found in a School, Hospital, or Office Setting

• If a single case of hepatitis A is identified in a school (other than a child care setting in which children wear diapers), office, or other work setting, and if the source of infection is outside the school or work setting, post-exposure prophylaxis (i.e., injection of IG or hepatitis A vaccine) is not routinely recommended.
• Similarly, when a person who has hepatitis A is admitted to a hospital, staff should not routinely be administered post-exposure prophylaxis; instead, careful hygienic practices should be emphasized.
• However, if it is determined that hepatitis A has been spread among students in a school or among patients and staff in a hospital, post-exposure prophylaxis should be administered to unvaccinated persons who have had close contact with an infected person.

References

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